Investigation of an Opioid Prescribing Protocol After Third Molar Extraction Procedures.

PURPOSE: The United States is experiencing an epidemic of opioid overdoses and deaths. The relation between prescription opioids and opioid abuse is well documented. Oral and maxillofacial surgeons and other dentists are proportionately among the most prevalent prescribers of opioids. Practitioners are looking for evidence-based ways to decrease excess opioid prescriptions and adequately manage postoperative pain. The authors recently analyzed the impact of a mandated nonopioid prescribing protocol at their institution. Although broad guidelines have been useful for treating postoperative pain, there are no procedure-specific guidelines for managing pain after third molar extraction. The purpose of this study was to determine whether an opioid prescribing protocol was sufficient to decrease opioid prescribing after third molar extractions. MATERIALS AND METHODS: This retrospective study compared the use of opioids prescribed for patients undergoing third molar extraction before introducing and after implementing a postoperative opioid prescribing protocol. The inclusion criterion was third molar extraction performed at the Division of Oral and Maxillofacial Surgery at the University of Minnesota (Minneapolis, MN) during the fourth quarters of 2015 and 2017 with complete records. RESULTS: The number of opioid prescriptions decreased and the number of nonopioid analgesics prescribed increased for all procedure codes after implementation of the protocol. Higher Current Dental Terminology (CDT) codes were associated with increased opioid prescriptions, indicating increased surgical difficulty was a rationale for opioid prescriptions. The mean number of opioid tablets per prescription was 15.9 in 2015 and decreased to 11.5 in 2017. No statistical difference was observed for average tablets for various CDT codes. CONCLUSION: Data from this study suggest an acute postoperative pain opioid prescribing protocol leads to fewer opioid prescriptions after third molar extraction procedures, less variance in opioid prescribing among practitioners, a decreased number of opioid tablets prescribed per patient, and safe and effective management of acute postoperative pain.

A biologic model for assessment of osseous strain patterns and plating systems in the human maxilla.

PURPOSE: This study was conducted to examine a biomechanical model and to help answer fundamental questions that relate to rigid plate fixation in the maxilla. Specifically, we sought to elucidate the principal strain patterns generated in the maxilla secondary to masticatory forces as well as the amount of permanent deformational changes incurred due to these loading forces. MATERIALS AND METHODS: Cadaveric heads with the mandible removed were defleshed and placed in a 2-part testing rig to hold and position the skull for testing in a standard material testing system. Rosette strain gages were attached at predefined points on the skull, and an Instron machine was used to load the skull through the loading port on the tray. A Le Fort I osteotomy was then performed on the skull, and a Walter Lorenz Ultra-Micro plating system was applied by a surgeon to reconnect the upper jaw. A 2-mm gap was left at the line of the osteotomy, and a transducer was attached to measure closure of the gap. Again the skull was loaded with the Instron (Canton, MA) machine. RESULTS: The results indicate a linear relationship exists with both maximum (tensile) and minimum (compressive) strain patterns relative to incremental load placement on the intact maxilla. The strain patterns after the Le Fort I osteotomy and plating were different and less linear. The differential variable reluctance transducer data showed a low rate of closure or transient increase in the gap at low loads (0 to 15 kilopond [kp] range) and a steeper slope of closure during high loads (15 to 60 kp range). It is also evident that axial loading forces cause permanent deformation and failure of osseous plating systems predominantly through bending. CONCLUSIONS: This model provides a foundation of knowledge regarding biomechanical strains in the maxilla subjected to static compressive loads in the force range of mastication. In addition, it serves as a comparative reference to assess rigidity of various craniofacial plating systems and to validate proposed standardized synthetic models. With the advent of increasingly precise surgery and new plating systems, this model can be used to help guide placement and design of plating systems; thereby allowing for ideal stabilization and optimizing surgical outcome.