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that they most commonly prescribed hydrocodone with acetaminophen, on average 20 tablets, after third molar extractions14. 3 • DENTAL OPIOID PRESCRIPTIONS IN PATIENTS UNDER 25 - Opioids prescribed after 3rd molar extractions are frequently the first opioid experience that adolescents and young adults have. In South Carolina in 2012-2013, dentists prescribed 44.9% of initial fill opioid prescriptions even though they made up only 8.9% of unique prescribers15. For patients aged 10 to 19 years, dentists are the main prescribers (30.8%, 0.7 million) and patients aged 10 to 29 are the most likely to abuse drugs and develop addiction16. This is important because brains don’t fully develop until around age 25. Opioid use in patients under the age of 25 can alter brain development and patients that have been exposed to opioids in adolescence are more likely to develop substance use disorders and addiction. One study found that legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse by the age of 23 among low risk individuals17. Clinical Summary of Common Dental Pain Medications • NSAIDs - Several state dental boards and associations, as well as quality improvement organizations, have endorsed the use of evidence-based, non-opioid analgesics for the treatment of acute dental pain18-21. NSAIDs provide effective pain relief for the most common acute dental complaints and procedures, as this pain is often caused by bone, pulp, and gum inflammation8,22- 30. For this reason, the ADA recommends NSAIDs as the first line treatment option for acute dental pain31. Studies have found that NSAIDs taken after a dental procedure are at least as effective (or superior to) opioid analgesics for reducing frequency and intensity of acute dental pain32. The FDA has strengthened warnings regarding the risk of cardiovascular events and other safety considerations associated with NSAIDs. However, data suggests use of most NSAIDs for < 10 days is not associated with increased risk of cardiovascular, gastrointestinal, or renal adverse events in the general population33. Proton pump inhibitors (PPIs) can be prescribed in combination with NSAIDs for patients that have a history of gastrointestinal (GI) disturbances with NSAIDs. If one class of NSAID is not effective, another class of NSAID can be considered. Caution should be exercised when using NSAIDs for acute pain management in special populations as outlined below and in patients already taking an NSAID. • ACETAMINOPHEN (APAP) - Acetaminophen has been shown to have a synergistic effect when administered with NSAIDs for the treatment of acute dental pain, with efficacy similar or superior to opioid therapy8,23,26,27,30,34,35. The total acetaminophen dose from ALL sources (including opioid fixed dose combinations) should not exceed 3,000 mg daily (4,000 mg daily if monitored). Patients should be counseled not to combine acetaminophen prescriptions with other over the counter medications containing acetaminophen. • OPIOIDS – Opioids can cause serious adverse effects such as sedation, respiratory depression, addiction, and death36. These risks are even greater in children. Opioid medications, such as hydrocodone/acetaminophen, tramadol, and codeine/acetaminophen, have been shown in multiple studies to be less effective or no more effective than NSAIDs for the treatment of postoperative acute dental pain, as they do not