BILL KLAPROTH: This is OMS Voices, an OMS podcast. I’m Bill Klaproth, and with me is Dr. Jim Swift, who is here to discuss pain control after oral surgery. Dr. Swift, thanks for being here. Always great to see you.  

JIM SWIFT: Pleasure to be here, Bill. Good to see you again as well. 

BILL KLAPROTH: Yeah, thank you very much. So, what is the usual primary option for pain relief after oral surgery?

JIM SWIFT: Well, that’s somewhat dependent upon the procedure that you perform and the difficulty of the procedure, how much time it takes to do the operation and, to some degree, the expectation of the patient. It’s a reasonable thing to ask the patient if you’ve had surgery before, of this type or of any nature, what worked for you as far as pain relief is concerned. It’s just how do you respond to pain and get the right analgesic components to make the patient have less pain.  

BILL KLAPROTH: So if a person never has had opioids or that type of pain medication, if opioids are considered necessary, then what are the considerations if the person has never had this type of pain medication?  

JIM SWIFT: Well, I wouldn’t start with opioids. Opioids are very effective pain relievers. But we also know that alternatives that are non-opioids also work well. And some patients would feel nervous if they had a procedure that they think is going to be associated with significant pain if you don’t give them an opioid. And so in many situations, they may request, even though they may have no opioid experience. And so there’s a little dialogue that takes place there. And if you’re talking to someone’s guardian or parent, they obviously don’t want their dependent to have pain or discomfort if it’s not necessary for that to occur. And so they’ll many times try to guide your decision-making because they know that if in fact the individual that they’re managing has pain or discomfort, that they’ll be responsible to try to take care of that. 

BILL KLAPROTH: Well, there is so much information and news about opioids and the opioid crisis right now. I would imagine that is a topic of discussion every time.

JIM SWIFT: It is, and it should be, to warn individuals of the dangers of some type of opioid dependence that isn’t a significant challenge in all situations, but it could be a challenge. 

BILL KLAPROTH: So if opioids are necessary, then how do you determine if opioids are necessary, and what are the considerations?

JIM SWIFT: Sometimes it’s a wait and see, you start with the analgesics that are less dangerous than opioids. And if those are not working, then you have the opportunity to come in with something stronger. Opioids are good pain relievers. And that’s why they’re utilized. But, and if you talk to an orthopedic surgeon, they all say the same things that an oral surgeon may say, because we’re doing operations around bone. And we’re doing bone and teeth. People are afraid of tooth pain. And in those situations, we have to see what works first. And then if in fact it’s not working, then we can move to something more effective. 

BILL KLAPROTH: Absolutely, so then how are OMSs educated on patient safety when it comes to prescribing?

JIM SWIFT: They should be educated by their training program and experiences they have there. And so you have to make sure that you do everything you can to minimize the amount of postoperative pain that anyone has. And there are several things you can do, the first is warning the patient preoperatively regarding the procedure. If you’re doing a procedure in multiple sites. If you’re taking out four wisdom teeth, that’s four separate surgical sites, four different incisions. And so it’s a little bit more challenging from that perspective. 

BILL KLAPROTH: You could expand on the other options, are there procedures that you follow?

JIM SWIFT: In fact, there have been research studies that have shown that if in fact you make the pill look mean and ugly, like you make it green and black, for example, instead of a white pill, that’s going to give people more pain relief. And based upon studies that have been done, they say, well, I had less pain with that green and black pill. And so some of it is psychosomatic. But, there needs to be in a belief that your pain relief system will work. And you have to put faith in that and say, well, if in fact you take these medications, aspirin-like medications or acetaminophen and nonsteroidal anti-inflammatory drugs, or acetaminophen, more commonly known as Tylenol, that those drugs do work for pain relief in the dental environment or in the oral surgery environment. But many people don’t have confidence because I think if I can buy that on the shelf of a drug store or a supermarket, it must not be very strong. And so they lose the faith or confidence that that is going to work. And so the surgeon has to be consistent with what they tell the patients saying that the studies show us that these medications will work to manage your pain. And you have to give them an opportunity to work in the way that I tell you to do it. So one way is to tell them to take the pain medication before the pain begins. Because when we take out teeth, we’ve given them local anesthetic first. And so that takes a while to wear off if you will, to return to normal feeling. And so if you just wait until it hurts and then you take your pain pill, it will be more difficult to relieve the pain, regardless of what kind of pain pill you’re using. And so you have to tell them: Be ready; take the pill before you get pain. And in some situations, clinicians will give them pills before they leave the office, but not opioids necessarily, but give a nonsteroidal anti-inflammatory drug or acetaminophen – Tylenol, if you will – before they leave the office. So that you can say, OK, you need to get the pain relief started before you feel pain. And don’t wait until it hurts, but take this every four or five hours, which is the dose sequence. And if you do, then you’ll prevent the pain from occurring. Those types of things are things that you can use, and that helps you jump the faith to the patient that that drug is going to work for them.

BILL KLAPROTH: So there is a certain amount of patient education that’s involved in this.

JIM SWIFT: There is. 

BILL KLAPROTH: Because people think, oh, if I can buy it over the counter, this has got to be weak. This is not the good stuff. I need the good stuff to combat this pain. Right? So there is that patient education. And you said, make sure you take it before the pain starts, if it’s really going to work.

JIM SWIFT: That’s correct. 

BILL KLAPROTH: So that’s. And then if that doesn’t work, that’s when you’ll consider a stronger form of pain relief. That’s when you’ll go into different analgesics and then opioids, etc.?

JIM SWIFT: Opioids are good pain relievers. but They have significant risk. And so, yes, if you need to use an opioid, then you should use an opioid because you don’t want your patients suffering pain. But you also tell them that they need to do other things that will help them to recover. So you tell them to not potentially participate in any kind of vigorous exercise or any type of activity that’s going to tire them or make them more susceptible to some type of significant pain response. 

BILL KLAPROTH: Right, so is documentation important in recording medications then?

JIM SWIFT: Critically and, it’s also procurement of information, utilizing prescription monitoring programs. And many regulatory agencies require you to do that so that you can see if, in fact, the individual has been exposed to other opioids, or has other prescriptions, or has some type of abuse or substance-dependent behavior so that you can prevent from making a mistake to giving them analgesics that have opioids. 

BILL KLAPROTH: Right, so what considerations then do OMSs make during surgery in consideration of pain control? 

Dr. Jim Swift: Well, the decision should be made immediately prior to surgery to do the least invasive surgical procedure to minimize the surgical trauma to the tissue that’s being operated on. These techniques help reduce pain significantly. 

Bill Klaproth: So you’re saying that you discuss these options with the patient beforehand, and during surgery, you assess and decide on the level of invasiveness. Then, based on that, you determine the type of pain relief needed, possibly even over-the-counter medication? 

Dr. Jim Swift: That’s correct. For example, during a wisdom tooth removal, if the procedure involved cutting the tooth into pieces and removing a considerable amount of bone, this might necessitate stronger pain relief. Another approach is administering steroids like Dexamethasone, which can reduce postoperative swelling and pain. This is especially feasible since we often use sedation or general anesthesia. 

Bill Klaproth: What about handling recurrent pain post-surgery? 

Dr. Jim Swift: Recurrent pain is challenging, especially when patients are away from the office. If a patient requests a refill for opioids, it’s important to assess the situation. If they claim they lost or accidentally disposed of the opioids, it may indicate misuse. In such cases, I invite them back for a reassessment and explore other pain relief methods. 

Bill Klaproth: Have you encountered patients seeking opioids for reasons other than pain relief? 

Dr. Jim Swift: Yes, I recall a patient who requested opioids for a toothache but refused tooth extraction, which was a clear solution. It seemed like a ploy to obtain drugs. In such cases, it’s crucial not to facilitate drug misuse. 

Bill Klaproth: What should people know about postoperative pain in surgeries performed by an Oral and Maxillofacial Surgeon (OMS)? 

Dr. Jim Swift: It’s important to follow your doctor’s advice and treat the surgical site with care. I often explain to patients that oral surgery, like removing wisdom teeth, is similar to orthopedic surgery in terms of postoperative pain. Respect the recovery process and avoid strenuous activities. Our standard practice is to start with Acetaminophen and NSAIDs, and only use opioids if necessary, based on individual patient assessments. 

Bill Klaproth: Thank you, Dr. Swift, for your insights. 

Dr. Jim Swift: Thank you, Bill. I appreciate the time. 

Bill Klaproth: For more information and the full podcast library, please visit myOMS.org. And if you found this podcast helpful, please share it on your social media channels and don’t forget to subscribe. Thanks for listening.