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Letters: Dentistry and the opioid crisis

April 15, 2019

After reading Dr. George D. Conard Jr.'s letter in the March 4 issue of the ADA News regarding dentistry and the opioid crisis, I find myself in complete agreement with his views and observations. While dentistry's proportional contribution to the opioid problem in our country is reported to be in the mid-single digits from a percentage view, I believe even that is much higher than it need be.

As Dr. Conard did, I also served on my state's board of dental examiners. I served for 10 years with five years serving as chair. That was over 25 years ago, but according to my recollection, the majority of the disciplinary cases to come before the board even then dealt with illicit prescribing of controlled substances. The triggering mechanism for investigation in many of these cases was the very large number of doses that were being prescribed or ordered.

I practiced general dentistry for 42 years in a middle class predominantly blue collar area. My practice was made up, for the most part, of good hard-working, honest people. Many of them did not want to be, or often couldn't afford to be, referred out for treatment unless absolutely necessary. As a result, when people refused endodontic treatment or wouldn't take their children to a specialist for third molar removals, we did considerable exodontia in our office in order to serve our patient's needs. With common sense and informed and prudent case selection we provided a good safe accommodation for our patients. For about the first 20 years of my practice I prescribed codeine-based analgesics for postoperative pain control, because that is what was taught and was the prevailing standard.

In the mid-1980's after several good discussions about drug abuse with my good friend, who was the physician who practiced next door to me for many years, I essentially quit prescribing opioids or opioid derivative analgesics. On the very rare occasions that I did resort to an opioid, I had a rule to never have more than 10 doses dispensed. I relied almost exclusively on prescription strength anti-inflammatories (in some cases with pre-loading prior to treatment) and long-term local anesthetics. Very rarely did we have post-operative pain control problems except from the occasional patient who would inform me, "That stuff doesn't work on me. The only thing that I can take is Oxycotin or SynalgosDC." They would often still be perplexed when they observed that if I did prescribe their drug of choice, I had only ordered that 10 tablets be dispensed.

As I am sure many experienced practitioners will agree, another quite probably equally important part of post-operative pain control in dentistry is a genuine concern for the patient by taking the time to explain to the patient what they should expect to experience and then often following up with a phone call later in the day or in the evening of the procedure inquiring about the patient and allaying any concerns that they might have.

Based on my many years of clinical experience, I believe that if dental practitioners followed a protocol similar to what I have described, and that worked well for me and I am sure Dr. Conrad for many years, we could almost eliminate dentistry as a significant contributor to the opioid crisis in our country.

Marvin B. Dvorak D.D.S.
Omaha, Nebraska