Letter to the Editor
Dear Drs . Radack , Wong and Moni :
I first wanted to applaud the PDJ for featuring the article titled “ Turning the Tide of Opioid Addiction ” by Dean Costello ( March / April 2022 ). I still remember BJ sitting in my Pharmacology and Pain Control classes at Penn Dental Medicine , and obviously excelling in them . I also watched BJ progress as an Oral and Maxillofacial Surgery Resident , and it was during that training I realized that Dr . Costello was going to become a national leader in oral and maxillofacial surgery . I admit I didn ’ t realize at the time that he was also one day going to become a Dean . I believe his article does a very nice job summarizing the extent of the problem and how we as dental professionals can still do better in not contributing to opioid misuse ( even though recent statistics show opioid prescribing in organized dentistry is down around 50 % since its zenith ).
Dr . Costello ’ s observations that opioids were not required in the vast majority of patients following outpatient oral surgery procedures , after telling one of his residents to not employ opioids as initial scripts , is not surprising . Post-surgical dental pain is mainly driven by inflammation . There is a body of evidence that has supported the remarkable efficacy of nonsteroidal anti-inflammatory drugs ( NSAIDs ) and more recently , NSAIDs combined with acetaminophen , beginning in the early 1980s . Published studies by dentists with PhD training including Drs . Stephen Cooper ( Penn trained dentist and Penn and Temple faculty member ), Paul Desjardins , Raymond Dionne , Paul Moore ( Pitt trained dentist and faculty member ), Kenneth Hargreaves and myself laid the ground work for this . In fact , Dr . Moore and I , “ took a stab at analgesic recommendations ” based on the invasiveness of the procedure and / or the amount of anticipated postsurgical pain back as early as 2011 ( Compendium , April 2011 ; Volume 32 , Number 3 . “ Prescribing Recommendations for the Treatment of Acute Pain in Dentistry ”) and then updated this paper with another paper in JADA focusing on ibuprofen / acetaminophen combinations for postsurgical dental pain in 2014 ( JADA , 2013 ; 144 ( 8 ) “ Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions : Translating clinical research to dental practice ).
There are additional publications that followed , but I think my 21 minutes and 34 seconds of fame sums it up . ( YouTube , NASEM Health and Medicine Division channel , 7 / 9 / 2019 - Session 2 : Elliot Hersh ). Let ’ s say in this link I was not speaking to the typical CE crowd , and it is among the top honors in my career to present to this group .
But deans like Dr . Costello can have a tremendous positive impact in the oral health care that the next generation of dentists deliver . And his pledge that he has University of Pittsburgh dental students take shows them that he is passionate about addressing this awful disease . Our dean at Penn Dental Medicine , Dr . Mark Wolff , shares this same passion , for example by instituting intranasal naloxone training for our DMD students to treat opioid overdoses outside the dental school . Delivering optimal oral healthcare includes employing evidence-based strategies to treat acute dental pain and doing everything we can to avoid patients from becoming addicted to drugs that for the most part are not required . In fact , my colleagues and I have data supporting that only about 19 % of patients on an aroundthe-clock ibuprofen 400 mg / acetaminophen 500 mg regimen for three days require any opioids after dental impaction surgery . And in those 19 % who did , the median number of opioid containing pills used was 3 ( and not 23 ). Now if we can , with some precision , identify who those 19 % are likely to be prior to surgery , it would be another step in reducing unnecessary opioid scripts .
Sincerely , Elliot
Elliot V . Hersh DMD , MS , PhD Professor Oral Surgery / Pharmacology University of Pennsylvania School of Dental Medicine Email : evhersh @ upenn . edu
MAY / JUNE 2022 | PENNSYLVANIA DENTAL JOURNAL 7