Surprising Ways to Control Dental Pain Without Narcotics

Hi, everybody.

I'm Dr. Sandhya Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body as we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy, so take care of it in the most natural way. Welcome to part two with Dr. Torbaner, famous anesthesiologist in Beverly Hills and, you know, friend and colleague for about 20 years. We're going to be discussing pain control after dental procedures, a great topic for anybody out there interested in having dental procedures or for those dentists that are listening that want to improve their pain control after, let's say, a tooth extraction or maybe just regular dentistry, mercury, safe removal, veneers, all that. So welcome back, Dr. Torbiner.

Hello.

Yeah. So let's talk about this, this very important subject, because, let's face it, nobody wants to have pain. And it's the pain anticipation that keeps people away from the dental office. So how can we minimize this?

All right. Well, the first thing is the goal we always have is to have no pain during and after. That's the goal. Nevertheless, before the procedure, we go through everything, and I tell all pat patients, even though I try so hard to have no pain, they may be sore and swollen for five to seven days after advanced gum surgeries and extractions and such, when that almost never happens, because we want patients to anticipate the worst and be surprised when it's not. Because if patients are aware, they tolerate things better. People who are anxious, their pain threshold goes down when they're comfortable, they've been told the truth, their ability to tolerate things is better. Nevertheless, you try to avoid pain. And how do we do that? We first instruct the patient during the procedure. Obviously, we keep them numb with local anesthetics of various kind. The local anesthetics with the maximum time, with a limited amount of epinephrine. We want as little epinephrine with maximum pain control. And there are various formulations we use.

Now, why. Why do you want the minimum epinephrine?

And that's a good question. Epinephrine's effects have various. Obviously, the epinephrine in a cartridge is various concentrations. Epinephrine in the cartridge can affect the heart rate and rhythm, specifically for patients. It can also affect blood pressure. But the real big issues for most patients are heart rate and rhythm, but those are gone usually within five to eight minutes because the epinephrine is Gone. So we try to give as little as possible with a long acting local such as marcaine, where I can give one shot in the lower gum and you'll be numb for three to six hours or longer. Which means I don't have to repeat the epinephrine, I don't have to repeat the local anesthetic. That giving less local with more pain control as an example. Now what we do during the procedures is obviously we keep them pain free throughout via local anesthetics and the intravenous anesthesia. The, that's the easy part for us.

The hard part for those of you listening, because I know we have people that are general consumers going to the dentist. What we're talking about is the local numbing agents. And some of you might say, oh, is it novocaine? Novocaine is just an old name and I guess, you know, typically refer to that when they bunch everything in. But marcane is one of those, you know, dental anesthetics that we use. And me as a periodontist, I also use it a lot for, you know, for long term anesthetic effects. But there's. So there's anesthetics with epinephrine and without any epinephrine. And I know I have some patients actually especially, you know, on the holistic side that say, oh, I don't want any epinephrine at all. I'm allergic to it because, you know, I get heart palpitation. Can someone be allergic to epinephrine?

No. There is no such thing as allergy to epinephrine. There are side effects. There are some people who are sensitive to the effects of the epinephrine or it could be the injection. It's difficult to distinguish. Some people think it's the epinephrine, but they don't like the shot and that makes them anxious and they may blame it on the epinephrine. There are some people who get palpitations from the epinephrine. How do we avoid this? Multiple ways. We can use a more dilute version with very little epinephrine or a different formulation that has norepinephrine, which affects heart rate less. There's something called carbocaine with neocoberin as opposed to the typical local anesthetic like lidocaine or marcane with epinephrine. And the neocobe does not cause heart palpitations. But you can only use that on young, healthy patients, older patients, that one can cause heart blood pressure increases significant. So that's only for young patients. But most of the patients who complain of palpitations that be young, healthy and say, I get palpitations. So you can go to that, or you can use something plain without epinephrine and a little bit of epinephrine to combine it so you, you minimize it. Other ways we avoid this is with sedation. When patients have palpitations or are nervous about the epinephrine, we often sedate them and the palpitations for some reason don't occur. So that's the way to avoid it either way, either with limited epinephrine, a different local anesthetic, or IV sedation in conjunction with the local anesthetic, where we watch the heart rate. And we rarely see any palpitations when we do that, almost never. So as I said, pain control is something that we try our best for complete pain control. So we do the procedure, we do the surgery, whether it's a major gum surgery, a bone graft, implants, sinus lifts, all the things you normally do for your patients. And they wake up. The first thing is we make sure they wake up numb. And the reason is we don't want them waking with acute discomfort. And we usually use a long acting local lense that lasts four to six hours, maybe even longer in the bottom and the top. This allows the patient to acclimate. We have found through research that where we keep them numb for the first six hours after surgery, the amount of pain reported on the fifth day is far less because we're ahead of the pain. So that's the first thing we do. The next thing we do, as you know, was you give Advil and Tylenol. Advil and Tylenol in combination. Now this is very important. People ask for Vicodin or percocet and such. 400 milligrams of Advil and a thousand milligrams of Tylenol in a healthy patient, that's two Advil and two extreme. Tylenol work far better than 30 milligrams of Vicodin. By research, 30 milligrams of VicodiN is far less successful at removing dental pain than two Advil and two extra strain Tylenol by reason.

So now you're saying take it together, right? That's all the time you take together. And why some people, I say, oh my God, that's a huge dose. Why would you take them together?

Because we have found that Advil by itself works better than Vicodin. Tylenol by itself works better, but by combining them, they work far Better and last longer. In other words, when we give the Advil and Tylenol together, we get stronger pain relief and a long. We get up to 6 hours Advil by itself. In the fifth hour, it starts to wane. Tylenol works faster than Advil in the first hour, but it wanes in the third, fourth hour when we combine them together. Combine them, we get pain relief that gives us a solid 6 hours and easy to take. So the standard dose for healthy patients of normal age is 2 Advil and 1000mg of Tylenol. As we get older or there's other issues, we tend to lower the tylenol to about 750. We always keep the Advil at 2 or 3. We don't like to give four Advil because it's too hard on the stomach. Causes. What happens is, what Advil does is it blocks one of the chemicals that causes pain. Prostaglandins. But prostaglandins do something good as well. They also prevent the acid from your stomach from bothering your stomach because it gives you other things that neutralize it. So what happens is when you take away that, you can get some stomach upset from the Advil. So how can we avoid that if we only do it for two or three days, as we do, it rarely happens. We also give Nexium 20mg once or twice a day, which prevents the antacids. A buffer for the Advil, which patients can take because the value of the Advil and Tylenol is so great, providing pain relief. Now we say, what about patients who need more? Generally speaking, we give patients a narcotic backup. We don't give them 50 pills, but we give them 10 or 12 or 14 pills of a narcotic, which they almost never need and should not need. But we like to make sure. I. I don't want patients in the middle of the night saying, it's not working. I need something else. Because I don't want their blood pressure, heart rate. So I'll usually give them 10, 12 pills of a narcotic as a backup that they almost never need.

Now, yeah, problem, huge problem in dentistry with narcotics. I think it's way over. Prescribing people give, like you said, like 30, 40, 50 pills at a time.

As a caveat, as a piece of information that I was looking up the other day. The United States is 5% of the world population. The United States prescribes 99 of all Vicodin prescriptions.

Oh, my God.

Now here's another one in Europe, they are 200 times less likely to give a narcotic than US physicians. We give 200 times more narcotics. They don't use them. They use the Advil and Tylenol. And there are other things we, of course do. When you're doing a surgery, Sonda, as we all know, we give them. We give you ice for the first day of the procedure. I like to do it. And of course you have. You probably know better. Of course you know better. We do ice the first day for swelling, which is a mediator of pain. And then the next day for the first hour, ice and then stop it after 24 hours. Where you allow, use warm salt water, rinses gently three times a day. It's a tablespoon or a teaspoon of salt and 8 ounces of water warm, just gently swishing. And this helps helps decrease the inflammation. It also, as you know, it neutralizes the bacteria. The bacteria don't like that alkaline solution, so it kills the bacteria and it draws the inflammatory fluid out of the tissue so the swelling is less. Swelling is also a mediator of pain. So those simple things, ice the first day, warm salt water rinses, Advil, Tylenol also. I don't like patients exercising for five days afterwards. Because when you exercise, it increases blood flow increase, you get a rebound pain and swelling. I know patients like to exercise, so don't exercise. Take it easy, follow the rules. The Advil, Tylenol, two or three days tends to be enough. And what about patients who say they want something more? We have a narcotic. Now you're going to say which narcotic. All narcotics work the same in equipotent doses. Let me say it again. All narcotics work the same in equipotent doses. They work on the mu receptors and the hypothalamus, making you feel better, pain free, but it also depresses your respiration and a few other things.

So whether you're talking about Vicodin or Percocet, they're all work the same way.

They all work. Now, here's the. Here's the one. There's a caveat to that too, of course. Vicodin in particular and Percocet to a lesser extent, are pro drugs. What does that mean? They come in a formulation, they come in a certain way, but it goes in the body must be broken down to its active form, so it comes inactive. And there's enzymes in our body that break it down to the active form. Approximately 10% of Americans lack that enzyme. So for example, if a patient tells me Vicodin doesn't work, it's because they lack the enzyme or Percocet. So it's not. What I usually say to the patient is, which narcotic worked for you in the past? That's when I'll give them. Well, what if you don't know and you want to be sure? The one to use that does not require enzymes is, there are a couple, but the one is diluted. People say, oh my God. Diluted. Diluted hydromorphone does not require enzymatic breakdown. It comes the way it works. What you see is what you get and it works without requiring it. So you have to worry about a patient where they have the enzyme or not say, oh my God, that's much worse than Vicodin. Not true. Vicodin in its active form after being taken, after the enzyme works on it is diluted. It's just a lower thing. So you can give a lower dose and you don't have to give a lot of pills. You have one or two. Now there are other issues as well, such as nausea and stuff. So somebody's from the narcotic afterwards. So we give them medication for that if they need it. But I want to emphasize most patients do not need the narcotics. The adventon work best. I like to give them as an in case they need it. And of course, all patients have our cell phone to call us if it's an issue. Yeah, of course they can do something else if they're, if they're still in pain the next day, they can come back to the office and get a long acting local anesthetic. They don't want narcotics and they want to be numb. They can come back to see you and you can numb it for another six hours. If it's that bad, which is very rare.

Yeah, it is.

Do really well.

I want to say in the last 20 years, definitely using the combination on Advil and Tylenol, most people didn't even use their narcotic prescription. And most of the time for a simpler procedure, I don't prescribe narcotics because they're not needed. Now I have some patients that say, oh, you know, to take a leave. It works better for me. Can they do a leave in Tylenol? Would you recommend that?

The answer is they can. They work the same. They work the same. The issue is the Advil and Tylenol is simpler because they're both every six hours. It makes it easier. Now some patients will tell you, I want to take the Advil. Every three hours, Every six. And the Tylenol every three. And I alternate them every three. That it's too complicated and it doesn't work better. It does not work better. When you give the proper dose of Advil and Tylenol every six hours. Great. You can do the Aleve, but then the aleve is every eight to 12 hours and the Tylenol is every six hours. I can't do that math. It's too complicated for me. So for a couple days, and they work the same. Now, someone's going to ask about Toradol. Toradol, the other. Now, Toradol, which is injectable and oral, is also a pain reliever. Is it better than Advil for dentistry? The answer is absolutely no. Absolutely. The value in a dental office is I can inject it iv. So for some reason, I have a patient at the end who's uncomfortable, which is rare, and I cannot add local anesthetic. I can't. For some reason, they've had too much and worry about the epinephrine or what have you. I can give the Toradol IV and have an effect in about 10 minutes, a good effect. I can give it intramuscularly and have an effect in 18 minutes. But for dentistry, it is no better. And it tends to cause more kidney problems and more stomach distress. That's kind of the kind of thing you want to use one time if we're in the office and I can't do other things and I have to go to that for whatever the reason, I'll do it then. Now, one place where Toradol for sure works better, and this may be for the consumers is kidney stones. And I have a story from my own life about kidney stones. Anyone who's listening has had kidney stones, know that that's can be very uncomfortable. And in my life, I think I've had over 20 kidney stones.

Wow.

Yeah. You're causing them, Sonda.

No, I'm sorry. I have a great tea for you from Dr. Schultz that will.

One time. One time, my kidney stone pain was so horrible, and I was going to see my urologist and I take an Advil and Tylenol and I went to the office and he said, I want to give you a Toradol shot. And I said, I took the Advil and Tylenol. He said, trust me. So the nurse gave me an intramuscular injection of toradol, and in 14 minutes and 21 seconds, the worst pain of my life was gone completely from a Toradol injection. From that time On I take tartal everywhere I go in the world in case I have a kidney stone thing. Now Also, it lasted four hours and 15 minutes, not six hours. Okay, so you at the non steroidals by themselves will not last as long unless you add Tylenol. But there are cases in other parts of medicine where Toradol is superior to Advil. But not in dentistry. Not in dentistry.

Interesting. Yeah. Because I do know dentists, they use Toradol intramuscularly as an injection for it.

But well, the other thing is you don't want to inject if you don't have to. If I can give it orally, generally speaking, let's say you have an allergic reaction to something such as look, use an antibiotic. If you have an allergic reaction to an oral antibiotic, it's unlikely to be a serious reaction. In other words, we can save you injectable reactions say from an antibiotic, which is rare. We're very careful. But if it does happen, even if we do everything right, the patient may not survive. But orally they will. So when you can avoid giving an injection of something that has a higher degree of allergenicity, such as antibiotics and to a lesser extent, but still non steroidals, better to give orally if you can.

Got it. Now, speaking of, you know, injecting medications, do you ever do IV pain medication control iv?

Well, the answer is usually not. We do occasionally. For example, there have been cases where at the end of the procedure I need to use a narcotic or what have you, whatever the patient needs. Usually we use it tore it off. We have to the end local anesthetic because local anesthetics are our best pain relievers on. There's nothing more clear than that than do that. We don't give chronic pain medication. That's for cancer patients and such like that which are handled by pain specialists specifically for that intractable pain. And usually they're using long acting oral pain medications such as OxyContin. I know that's a bad name, but for the cancer patients it can be valuable.

Now steroids, okay. They like to use steroids iv. Do they help pain or.

Yeah, the answer is yes, we use them. We use dexamethasone usually. And whether it helps with pain or not is still under investigation. There are some studies that seem to say yes, others that say maybe not. But it does help with swelling and swelling which does media manifest as pain after several days. So we think that we use it. So we use one dose usually before I start, which helps with swelling and may help with pain. I don't have the research to say yes or no. If you're not doing anesthesia, you can give 8 milligrams of dexamethasone before the procedure, which may help with. Will help with swelling, it may help with pain. Now, you can't use it in patients with blood sugar problems or who have immune problems and such as. Or psychosis issues. But for healthy patients or normal patients, you can give an 8 milligram dose before the procedure, which may help you with pain control and swelling.

Yeah, I mean, I like dexamethasone for, let's say people come in for wisdom teeth extraction. You know, that could be pretty debilitating. When it swells up, you can't even open your mouth to actually have food. So for those kind of instances, I think it's beneficial we return.

We routinely give it for you, as you know.

Sandha yes, exactly. Now, let's talk about some side effects for, for some of these medications for pain control. One of them we talked about is nausea, of course, when we talk about narcotics. Any other side effects?

Well, as you know, with Advil, there's GI upset, stomach upset because of the acid. We discussed earlier the acid buildup from that because the prostaglandins are not around to buffer the acid. And that's a. So you. And that usually when we do it for two or three days, doesn't happen. Nevertheless, we have Nexium for patients to take to try to avoid that should they have stomach. Also if they do get stomach upset, it does happen once in a while. When they do, we stop the medication immediately and continue with just Tylenol and hopefully that's enough to do that along with warm saltwater rinses and such. In rare instances where we can't use the Advil, we have to resort to narcotics as a supplement. We cannot use it because of stomach distress or, or we cannot use Advil in patients on blood thinners or kidney disease. Those are cases where we can or if they're allergic to it. So in those cases we go to the Tylenol. If we can warm salt water, if we have in the long acting local anesthetic and if we have to, we use a narcotic as a backup.

Then, you know, some people listening are like, you know what? I'd rather take the pain. But you know, believe it or not, there's actually side effects to pain as well. What kind of physiological things happen when people are in chronic?

Heart rate changes, blood pressure changes, which are very bad. Of course. And there's, there's depression. I mean, I, you know, I've never really had chronic pain. I once had a back problem for eight days and by the seventh or eighth day I had this pinched nerve is pretty upsetting. I can. And people are in pain all the time. So you want to avoid chronic pain, which is debilitating, upsetting and frustrating. And we're all different. Some of us can handle pain better than others. So we have to treat every patient and understand what their needs, desires and what they can tolerate. And because someone can't tolerate pain doesn't mean we should tell them to take it. We should find a way to solve the problem as we try every time, as you know.

Yeah, absolutely. I mean, when we need medication, that's what it's there for. You know, obviously chronic use of any medication is dangerous, but when you really need it, it's actually beneficial.

One more thing I want to talk about, because we talked about narcotics earlier, this is, I think it's an important point, is that, that young people between the ages 12 and 17, we should avoid narcotics at all costs. And the reason why, and the reason is the brains are still plastic then. And data has now been released where, where kids under the age of, I think it's 19 who had a narcotic prescription were 15 times more likely to develop a narcotic addiction later in life. This is from a prescription from wisdom people. So in those patients who go for wisdom teeth, and I do this up to age 21, 22, Advil, Tylenol, Ice and then warm water, because those patients can handle a little bit of soreness, the risk of narcotics when you have a 15 time increase in drug addictions. Now as an aside, people who become drug addicts in general, 60% start with prescriptions, 40 from street drugs, 60 from prescriptions. And it usually follows a certain pathway. It's first alcohol, then it's thc, then it's narcotics. That's the general pathway to drug addiction. But we as practitioners should, and, and parents who are listening out there, who have kids are having their wisdom teeth, take the Advil and Tylenol, use the ice, use the warm saltwater rinses, avoid their narcotics if at all possible because it's, there are long term sequelae there which none of us want.

Yeah, that's, that's an amazing statistics that you just quoted. Under the age of 19.

Yes, yes, yes, yes.

Which is when everybody takes out their wisdom teeth. Tramadol is something that some patients ask for. Is tramadol a Narcotic. Do you recommend it for dental pain?

First of all, as I said to you, if someone wants Tramadol for their pain after we told them Advil, Tylenol works best. But some can't take Advil, Tylenol. But let's say if they. If they can, we encourage that. A Tramadol is a narcotic. It has addiction like any other narcotic. It's kind of a crappy narcotic, not a very effective narcotic. Okay. It's kind of in that Tylenol with codeine area where it doesn't really work. As an aside, Tylenol with codeine. They did a study. They compared Tylenol with codeine versus placebo. How effective they were after wisdom teeth. One out of every 17 patients with Tylenol coding. So they had pain relief. One out of 18 with placebo.

Wow, that's crazy. So might as well just stick our sugar pill.

Yeah. So the answer is tramadol is kind of a crappy narcotic, but it's a narcotic. They all work the same way. They all work on that, Those mu receptors in the hypothalamus. It's just kind of a low dose. And the reason it's being used is because pharmacies, unfortunately, are not stocking Percocet, Dilaudid, as they should. In fact, some patients need them because of the current feelings about narcotic abuse and the explosion of deaths. And this is from street drugs of narcotics. As an aside, since I'm remembering this now, for those of you listening who have kids of high school age and such, there's a lot of fentanyl and powder and such at parties. And you can be sitting next to someone and you can sniff it, and you could end up overdosing yourself. So they now have available the reversal, the nasal spray. Naloxone. Naloxone reversal spray, all this. You can get that over the counter. You can buy it yourself. It's now available to buy. So anyone who goes to parties, who see some kid who just faints for whatever the reason, assume the worst. Give them naloxone nasal spray, call 911 right away. If they fainted for another reason, then naloxone will not hurt them. But if it was from a drug overdose, you can help keep them alive till help comes. Everyone should carry those. All kids who go to parties or in places where someone might be doing something they don't know, and you end up inhaling it and end up yourself, overdosed.

Wow. This is great information, Dr. Jordana. Naloxone. And probably it's even available online, probably on Amazon.

Also known as Narcan.

Yes, Narcan. Okay. It could save someone's life just by having this.

Absolutely.

Okay, so Tramadol and Tylenol 3 do not use. They're not really helpful. Might as well just go with Advil and Tylenol. Two Advils, two Tylenols. Great advice. Very enlightening conversation. I think anybody listening to this segment got a lot out of it. Just like me. You always teach me something, so thank you for that. And for those of you that are looking to get IV sedation, you can click the link below. There's information, information how you can find Dr. Torbiner in the show notes. Dr. Torbiner, thank you so much for being with us for the last couple of episodes. Any last words of wisdom before we close?

No. Thank you for having me, son. It's been a pleasure and good luck to everyone out there.

Thank you. For those of you actually that want to leave a comment, go to our YouTube channel and ask Dr. Sandha where you can see this video episode and leave your comments. Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question you'd like me to answer? Message me on Instagram. DoctorsAnda. This is Dr. Sandha. And remember, your mouth is the gateway to your health. So take care of it in the most natural and best way possible.