Pain Pain is a frequently reported side effect associated with oral surgical procedures; it prompts the highest number of after- hours emergency calls received by dental practitioners (Bird & Robinson, 2015). In wisdom tooth extraction, for example, pain after surgery and dry socket are the most common complications (Cho et al., 2017). There are about 2 million visits made to U.S. emergency departments for dental issues each year. A study noted that people treated in the emergency department for dental problems usually have an infection, pain, or both (Sun et al., 2015). As a general rule of practice, postsurgical pain should be treated with the mildest effective medication. Gingival and osseous tissue pain can often be controlled by the peripheral effects of aspirin, acetaminophen, or their derivatives; if necessary, narcotics such as codeine phosphate or its synthetic agents may be required. Narcotic medications such as Synalgos-DC (aspirin/caffeine/dihydrocodeine) or Vicodin (acetaminophen and hydrocodone) may be better tolerated by patients than products with codeine phosphate (e.g., Tylenol with Codeine No. 3 or Vopac). Oral surgery patients should be instructed to ingest yogurt, cottage cheese, or ginger ale before taking any pain medications in order to prevent nausea. Patients should be instructed to begin taking the pain medication upon returning home from the procedure, rather than waiting for the effect of the local anesthetic to diminish. Preventing a sudden onset of postsurgical pain when the local anesthetic wears off makes pain control easier and more predictable for the patient. Pretreatment analgesics, especially ibuprofen, may also help reduce postoperative pain (Bailey, 2018). The dental practitioner should consider the U.S. Drug Enforcement Administration (DEA) drug schedules if the patient’s pain level warrants an increase from a Schedule III drug (e.g., Synalgos-DC or Tylenol with Codeine No. 3) to a Schedule II drug (e.g., Vicodin or Vicodin ES). The DEA groups prescription drugs into five schedules according to their potential for abuse, with Schedule I drugs having the highest abuse potential (U.S. Department of Justice, n.d.a). For example, a Schedule II drug has a high abuse potential and risk of severe psychic or physical Edema Edema usually manifests postoperatively within 24 to 48 hours. Researchers believe that some patients have a greater potential for swelling than others (Yaedu et al., 2018). Longer and more involved procedures increase the potential for swelling, especially when more osseous tissue is incised. This swelling is normally related to the transection of lymphatics and capillaries as well as the inflammatory process caused by the surgical flap and bone removal. Performing an oral surgery procedure expediently, with as little trauma to the tissues as possible, may minimize edema. Postoperatively, edema can be minimized by placing an ice pack on the outside of the affected area every 20 minutes (on and off) during the first 24 hours. Application of cold compresses Trismus Trismus, or difficulty opening the mouth, may result from infection or temporomandibular joint trauma. Trismus is also commonly the result of injury to the medial pterygoid muscle during the administration of local anesthesia for an inferior alveolar nerve block. Inflammation resulting from wisdom tooth removal can also cause trismus as the muscles near the extraction site become involved in the inflammatory process (Hupp et al., 2014; Larsen et al., 2021). Trismus often peaks within 24 hours and then begins to abate. When wisdom teeth are removed surgically, patients should be advised ahead of time that they may not be able to fully open their mouths for one to two days after the procedure.
dependence, despite having accepted medical usages. The DEA requires the practitioner to write and sign any prescription for Schedule II drugs (U.S. Department of Justice, n.d.b). A Schedule III drug has a significant abuse potential as well, but it is not as severe as the risks associated with drugs from Schedule II and Schedule I. Because of these decreased risks, the DEA allows a pharmacist to receive a Schedule III drug prescription from a practitioner orally, in writing, or by fax. The opioid crisis is a pandemic that is not restricted to the U.S. More than 16,000 people died in 2020 as a result of prescription opioids, totaling 18% of all opioid deaths (CDC, 2022). Many states have enacted prescription-monitoring programs that collect data about prescriptions for controlled substances such as opioid analgesics (Keith et al., 2018). It is beyond the scope of this discussion to highlight recent laws that limit the duration of an opioid prescription. Each dental clinician who prescribes these medications must be knowledgeable about how these regulations impact their opioid-prescribing practices. Since the combination of ibuprofen and acetaminophen, which is comparable to the opioid medications but does not have the potential for addiction, can provide pain relief, this combination should be considered before prescribing an opioid analgesic. The dosing regimen for dentoalveolar pain control is critical. Acetaminophen and nonsteroidal anti-inflammatory drugs such as ibuprofen are the medications of choice for postsurgical pain. The additive effects of the two medications have repeatedly shown a superior analgesic effect compared with either drug alone. They also have fewer side effects and less abuse potential compared with opioids (Colgate/American Dental Association, 2019). Many practitioners rely on the “2–4–24” mnemonic: “2 drugs, 4 doses, for 24 hours,” such as a combination of 400–600 mg of ibuprofen plus 650-1,000 mg of acetaminophen administered every 6 hours for 24 hours (Cho et al., 2017). Opioid-based analgesics such as hydrocodone and oxycodone should be reserved for the small percentage of dental patients with severe, uncontrolled pain. constricts the capillaries and reduces swelling at the surgical site (Fernandes et al., 2019). Corticosteroids may also be administered to decrease swelling and inflammation. Either dexamethasone or methylprednisolone may be administered intravenously, orally, or intramuscularly (Nehme et al., 2021; Shoohanizad & Parvin, 2020). Studies have found that dexamethasone administered in the submucosa can control edema when administered either before or after oral surgery (Sreesha et al., 2020). Patients should be advised to decrease physical activity for a few days following oral surgical procedures to decrease the risk of elevated blood pressure, which may result in increased edema. After about one week, surgical inflammation and trismus usually resolve (Hupp et al., 2014; Santiago-Rosado and Lewison, 2021). If the patient continues to experience moderate trismus more than one week after surgery, a baseline interincisal opening measurement should be recorded (Oral Cancer Foundation, 2016). Gentle passive motion should be implemented at that time to decrease inflammation and pain. Solutions range from inserting an increasing number of tongue depressors into the mouth to using a custom-made device several times daily until the trismus has subsided (Yu-Hsuan et al., 2019).
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