Dental Prescriptions for Young Children-Some Considerations...

This is a good subject to broach and discuss. The subject of opioid use, dependency, and deaths in this country (especially in our area of the country) has been on the minds of all clinicians that deal with acute and chronic pain. CDC Director Tom Frieden has spoken out about this recently saying “The epidemic of deaths involving opioids continues to worsen. Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.”  It’s also sad that more people died from heroin-related causes than from gun homicides in 2015. As recently as 2007, gun homicides outnumbered heroin deaths by more than 5 to 1.

This subject has been at the forefront of the pediatric community for some time and we, as a specialty group, are seeing opioids used less and less in children for acute pain. This has been reflected in the pediatric dental residency training programs over the last 10 years.  Even now, I don’t usually give a pediatric prescription for a narcotic and have never had one issue. Even when I have had to remove several baby teeth due to extensive cavities and multiple dental abscesses-the children do well with Ibuprofen.  My colleague (Dr. Jim Shealy) in Atlanta that has been practicing for over 20 years and owns three pediatric dental clinics and a surgicenter texted me this very quote last night: 

“Kids Motrin! The best! Just follow dosage on bottle… one dose when they get home… keep on the rest of day and one dose in the morning. parents tell me kids did well at post up office visit. I switch to Tylenol if given Toradol... 20 years… no problems!”    

In fact, on the written post-operative instructions I give to each parent in Pre-op say the following:  

“Will my child have pain?

• Your child received pain medication while asleep. It will begin to wear off in 2 hours.

• Begin with acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Motrin) to relieve discomfort. It is normal to have sensitive teeth after fillings and crowns are placed. Avoid hot or cold foods. 

• We will not give narcotic prescriptions to children.

• Pain can last for a few days. Call if the pain is greater on the third day after surgery.”

We know as pediatric specialists that there are safer drugs and treatment approaches that can control pain as well or better than opioids for the vast majority of our pediatric dental patients. I wanted to share some of the literature review I found over the weekend to help make this discussion simple.  

To start off with the “slam dunk” standard of care for pediatric dentistry- The AAPD Guideline on Pain Management reports that the extent of treatment affects post-operative pain and it has been reported that 95 percent of children undergoing full mouth dental rehabilitation, regardless of extent of treatment, report pain of moderate intensity. Pain scores usually are their highest immediately postoperatively while the patient is in the post-anesthesia recovery unit. 1 This is important for us to understand so that we as providers can prescribe appropriately. Since most cases of post- operative pain include an inflammatory component, NSAIDs are considered first line agents in the treatment of acute mild to moderate postoperative pain. Opioid analgesics provide analgesia for moderate to severe pain but have side effects including sedation and respiratory depression which is of most concern to us in pediatrics. Codeine, one of the most widely prescribed narcotics, is a prodrug that is metabolized into morphine in the liver. We have all read about the fact that recent, research has found a genetic polymorphism of the liver cytochrome enzyme which causes some patients to be ultra-rapid metabolizers of codeine. The patients will ultimately convert codeine into high levels of morphine very quickly and there is no way to reliably identify which patient might be an ultra-fast metabolizer other than a non-commercially available laboratory test. On the flip side we must consider that the other variant of this liver enzyme may cause patients to be poor metabolizers of codeine and consequently under-respond to the narcotic. Repeated doses of codeine/acetaminophen combinations sooner than six hours in these patients may result in acetaminophen overdose.2 Moving along, it is good to consider what our pediatric surgery colleagues consider for use for one of the most prevalent surgeries in children- tonsillectomies. Kelly, et al performed a randomized trial comparing morphine to Ibuprofen post tonsillectomy. They found that Ibuprofen in combination with acetaminophen provides safe and effective analgesia in children undergoing tonsillectomy. Post-tonsillectomy morphine use should be limited, as it may be unsafe in certain children. In fact, of the total 91 children that were in the study, the number of desaturation events increased substantially in the morphine group, with an average increase of 11.17 ± 15.02 desaturation events per hour (P < .01).3

Our colleagues in the pediatric ED see children with acute trauma and deal with pain control every day. In Friday and Kanegay’s randomized, double-blinded equivalence trial, Pediatric ED patients 5 to 17 years of age with acute traumatic extremity pain received acetaminophen–codeine (1 mg ⁄ kg as codeine, maxi- mum 60 mg) or ibuprofen (10 mg ⁄ kg, maximum 400 mg). Their study found similar performance of acetaminophen–codeine and ibuprofen in analgesic effectiveness among ED patients aged 5–17 years with acute traumatic extremity pain.4

Third molar exodontia is one of the most prevalent surgeries we see in Dentistry. Barden and Edwards wanted to compare the relative efficacy of analgesics after third molar extraction from systematic reviews of randomized, double blind studies. In their review it was only the narcotic (acetaminophen 600/650 mg plus codeine 60 mg) that was associated with any significant increase in any patient experiencing an adverse event.5

The Cochran Collaboration is known for the highest quality reviews because they strive to only consider randomized controlled trials. The recent review comparing Ibuprofen to Acetaminophen for post-operative analgesia after third molar extractions found that there is high quality evidence that ibuprofen is superior to acetaminophen at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively. 6 Focusing more in on the research in pediatric dentistry- in their randomized control trial of 154 children, Moore and Hargreaves objective was to evaluate the relative efficacies of four liquid analgesics in children, five to twelve years of age, following dental extractions. The analgesics, acetaminophen elixir (240 or 360 mg), acetaminophen with codeine elixir (240 mg and 24 mg, respectively), aluminum ibuprofen suspension (200 mg), and placebo liquid were administered at home, as a single dose. 4 hours post extraction, the global rating of drug efficacy was statistically superior for aluminum ibuprofen.7

We know that opioids are considered the cornerstone of management of severe acute pain; however, they have been associated with a number of adverse events in hospitalized pediatric patients. A recent study reported that 24% of children experienced an adverse drug event related to postoperative opioid use that required intervention, rescue doses, or an escalation in care. Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently employed as a strategy for reducing opioid requirements in children after surgery. A reduction in opioid use may, in turn, reduce the incidence or severity of adverse events, or both, associated with this class of analgesics.8  As Dr. Tom Frieden at the CDC explained: “We must not forget what got us here in the first place. Doctors’ prudent use of the prescription pad and renewed commitment to treat pain more safely and effectively based on what we know now about opioids—as well as healthy awareness of the risks and benefits among patients prescribed these drugs—can change the path of the opioid epidemic”.  

REFERENCES

1. Needleman HL, Harpayat S, Wu S, Allred EN, Berde C. Postoperative pain and other sequelae of dental rehabilitations performed on children under general anesthesia. Pediatric Dent 2008;30(2):111-21.

2. AAPD Guideline on Pain Management; Reference Manual V 37 No 6 15/16

3. Kelly LE1, Sommer DD, et al. Morphine or Ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics. 2015 Feb;135(2):307-13. doi: 10.1542/peds.2014-1906

4. Janet H. Friday, MD, John T. Kanegaye, MD et al. Ibuprofen Provides Analgesia Equivalent to Acetaminophen–Codeine in the Treatment of Acute Pain in Children with Extremity Injuries: A Randomized Clinical Trial. ACADEMIC EMERGENCY MEDICINE 2009; 16:711–716 2009 by the Society for Academic Emergency Medicine

5. Barden J, Edwards JE, et al. Relative efficacy of oral analgesics after third molar extraction. Br Dent J. 2004 Oct 9;197(7):407-11; discussion 397.

6. Edmund Bailey, Helen V Worthington , Arjen van Wijk, Julian M Yates, Paul Coulthard, Zahid Afzal. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database of Systematic Reviews 2013, Issue 12.

7. Moore PA, Acs G, Hargreaves JA. Postextraction pain relief in children: a clinical trial of liquid analgesics. Int J Clin Pharmacol Ther Toxicol. 1985 Nov;23(11):573-7

8. Rowe E, Cooper TE, McNicol ED. Ketorolac for postoperative pain in children. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD012294. DOI: 10.1002/14651858.CD012294.