CC
A 16-year-old female is referred for consultation regarding her third molars.
HPI
The patient desires extraction of her third molars before initiating orthodontic therapy, and she presents with her mother to her appointment. She is currently asymptomatic and denies any fever, swelling, or pain. She reports being very nervous, she is afraid of needles, and she does not want to feel any pain.
PMHX/PDHX/medications/allergies/SH/FH
The patient has uncontrolled depression and anxiety. She reports fear of the dentist with a low pain tolerance. She denies past surgeries and medications. She denies a history of alcohol, tobacco, or illicit drug use. She has no known drug allergies or family history of anesthesia complications.
Examination
General
The patient is a well-developed and well-nourished teenager in no acute distress.
Maxillofacial
There are no soft tissue abnormalities or cervical lymphadenopathy. There are no clicks or pain to palpation of the temporomandibular joints bilaterally. The muscles of mastication are nontender to palpation. Maximum interincisal opening is 4–5 mm with no lateral deviation upon open or close.
Intraoral
Examination of the oropharynx is without tonsillar hypertrophy, the uvula is midline, and the patient has a Mallampati score of 1. There are no visible lesions or pathology of the soft tissues. The patient has minimally restored dentition, stable occlusion, and fair oral hygiene; a bonded mandibular lingual retainer is present. All third molars are not visible intraorally. Probing depths are 6 mm distal to the mandibular second molars with no bleeding on probing. There is no tenderness to palpation, no erythema, and no signs of infection in the third molar regions.
Imaging
A panoramic radiograph reveals a minimally restored dentition and no pathology of the bones, joints, or sinuses in the field of view. Bonded retainer is present. All third molars are vertically impacted at the level of the adjacent teeth cementoenamel junction. There are greater than 50% root development and a lack of space to accommodate eruption. There is no interruption of the inferior alveolar canal.
Labs
No routine laboratory tests are indicated for the evaluation of impacted third molars unless dictated by underlying medical conditions.
Assessment
16-year-old ASA (American Society of Anesthesiologists physical status classification system) I female with a history of depression and anxiety with impacted third molar teeth. The patient and her mother elect for extraction of her asymptomatic maxillary and mandibular impacted third molars with local anesthesia and intravenous (IV) sedation.
Treatment
Intravenous sedation is indicated to reduce fear and anxiety during surgical removal of impacted third molars and to attempt to eliminate recall of the procedure. A combination of drugs is typically used to achieve a proper balance of sedative, amnestic, and analgesic effects with appropriate durations of action. The perioperative medications delivered have been shown to have an effect on the amount of postoperative pain the patient will experience and subsequently the amount of opioids prescribed. Counterintuitively, reducing the use of intraoperative opioids (in an effort to combat the epidemic) may actually result in a greater need for postoperative opioids. There is no significant evidence correlating the use of intraoperative opioids with addiction. Therefore, clinicians should not shy away from intraoperative opioid use when indicated. Opioid-sparing multimodal analgesia has been shown to augment and maximize pain control while combating the negative side effects of opioids (see Complications). This technique may include the perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, corticosteroids, long-acting local anesthetics, and other adjuncts such as ketamine.
The patient arrived at the clinic and was visibly nervous. A preoperative discussion was held with the patient and her mother to address their concerns, calm her fears, and answer all questions. They both expressed understanding that postoperative pain would be appropriately managed but not entirely eliminated. The mother was escorted back to the waiting room while monitors and oxygen were placed. IV access was obtained using distraction techniques. (Assistants discussed her pet animals at home while she looked away with consent.)
Midazolam was administered immediately for its amnestic and anxiolytic effects followed by slow titration of fentanyl to a comfortable state of conscious sedation. Dexamethasone was administered slowly to address postoperative inflammation and swelling and therefore indirectly reducing postoperative pain. Dexamethasone also carries the added benefit of preventing postoperative nausea and vomiting (PONV), which is a known side effect of opioids. At this point, ketamine may sometimes be considered for deeper sedation and adjunctive analgesia. However, there is no evidence to show IV ketamine for third molar surgery reduces postoperative pain or opioid consumption, particularly in patients who received intraoperative opioids. In this case, the patient was managed without ketamine. A throat pack and bite block were placed followed by administration of local anesthesia with adequate time allowed for profound effect. Specifically, lidocaine with epinephrine was injected in all four quadrants, in addition to longer-acting bupivacaine with epinephrine for the mandibular nerve blocks.
Surgery was completed routinely in 30 minutes with care to prevent iatrogenic injury and tissue trauma. There were no perioperative surgical or anesthetic complications. Surgical variables that have been shown to affect postoperative pain include duration of surgery, surgeon experience and technique, degree of difficulty of the extractions, and amount of hard and soft tissue damage. Despite attempts to limit surgical variables that cause postoperative pain, pain is not the same as nociception. Pain is a subjective experience that is highly variable from patient to patient based on biopsychosocial factors. The management of postoperative pain should therefore be individualized according to each patient and each surgery.
In this case, the patient’s young age and history of mental illness place her at a higher risk of the negative consequences of prescription opioids. Her quick and routine surgery, on the other hand, places her at a lower chance of prescription opioid requirement for adequate analgesia. A recent study in the Journal of Oral and Maxillofacial Surgery (JOMS) showed 93% of patients did not use any of their prescribed oxycodone after extraction of asymptomatic third molars. Among the small percentage who did, an average of 3.3 tablets were used, with the highest use on postoperative day 2. This patient was prescribed ibuprofen and acetaminophen as first-line analgesics to be taken around the clock on an alternating schedule. After a thorough discussion of the risks versus benefits of opioids, the patient and her mother declined an opioid prescription for breakthrough pain. This discussion was documented, and verbal and written postoperative instructions were provided along with an emergency contact number to call for the unlikely event of debilitating pain. The patient and her mother were reminded of the preoperative education regarding pain management expectations. A cross-sectional study in JOMS shows nearly half of parents do not feel comfortable with their children being prescribed opioids after third molar extractions. In addition, several reviews by the Cochrane Collaboration indicate the number needed to treat acute postoperative pain is actually lower for NSAIDs and acetaminophen compared with opioid monotherapy, suggesting opioids are less effective than nonopioid alternatives in this setting. Low-dose opioids do provide some benefit as a rescue medication for severe breakthrough pain, but this situation can usually be avoided with proper patient education and compliance.
Complications
Prescription opioids carry the potential to be both beneficial and harmful. The benefits may lead clinicians to overprescribe, whereas the risks may lead them to underprescribe. Both of these scenarios result in complications. Therefore, prescribing opioids is a balancing act that requires careful consideration of the risks, benefits, and alternatives.
The primary risk of underprescribing opioids is uncontrolled breakthrough pain after failed management with first-line agents. Common sequelae of untreated pain include functional impairment, increased morbidity, delayed healing and recovery time, increased health care costs, and undue emotional stress. The primary goal after surgery is pain modulation rather than pain elimination. Patients should be educated beforehand that some postoperative pain is acceptable as long as it does not affect their ability to perform daily activities such as eating, talking, or sleeping.
Alternatively, overprescribing opioids may lead to misuse, diversion, dependence, addiction, overdose, and death. Opioid use disorder , rather than opioid abuse , is the correct term used to recognize the condition as a medical diagnosis and not a moral failing. Risk factors for this include past or current substance use disorder, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. For chronic users, withdrawal from opioids may include nausea, diarrhea, muscle aches, insomnia, agitation, and depression. Long-term use may also lead to tolerance, thus requiring increased doses to achieve the same desired effect. Older adult patients, on the other hand, usually require lower doses because of altered metabolism.
Even for those without opioid use disorder or substance use disorder, opioids are not a benign substance. Common side effects of opioids include sedation, respiratory depression, PONV, urinary retention, and constipation. Opioid-induced respiratory depression may be exacerbated when combined with benzodiazepines or alcohol. In the event of an emergency, naloxone is a rapid opioid reversal that is essential for every surgical setting. It is imperative that clinicians routinely check expiration dates and know where their naloxone is located in the facility before administration of any opioids.
Discussion
The opioid epidemic has been described as a uniquely American problem, though it may soon be considered a global pandemic if we are not vigilant. It started in the mid-1990s when big pharmaceutical companies promoted OxyContin and exploited “pain as the fifth vital sign” to sell their products, triggering the first wave of overdose deaths. A second wave of deaths came around 2010 when people with existing addictions to opioids transitioned to the cheaper and more abundant drug heroin. More recently, a third wave of deaths has been driven primarily by stronger illicit synthetic opioids such as fentanyl, despite ongoing efforts from doctors to reduce unnecessary opioid prescriptions ( Fig. 10.1 ). According to the American Medical Association, the number of opioids prescribed has decreased by nearly 50% from their peak in 2011 until 2021. Doctors should not be discouraged, however, because the rise in deaths is more significantly correlated with dangerous illicit fentanyl as opposed to prescription overdoses. In fact, the onslaught of heroin and fentanyl catastrophes only underscores the importance of practicing safe stewardship over prescription opioids. Among heroin users in the United States, about four in five reported misusing prescription opioids before starting heroin, suggesting exposure to prescription opioids might be a gateway to cheaper and stronger alternatives.
