GP3d - Oral and Maxillofacial Surgeon Accuracy in Anticipating Supplemental Opioid Use Following Third Molar Extraction

Abstract: Anticipating which patients will require supplemental opioid use following third molar extraction is a challenge with significant benefits for oral and maxillofacial surgeons. Studies have attempted to link indices such as the Pederson Difficulty Index to post operative pain intensity with variable results. In this study we assess accuracy of surgeon prediction based on panoramic radiographs and the Pederson Difficulty Index in anticipating which patients will require supplemental opioids in addition to ibuprofen and acetaminophen for primary pain management following third molar surgery.

This is a secondary analysis of a randomized, double-blind clinical trial of 86 patients undergoing surgical extraction of ≥1 partially or full bony impacted mandibular third molar. All patients received ibuprofen and acetaminophen for pain management, and supplemental oxycodone use was documented. Four academic oral and maxillofacial surgeons used panoramic radiographs to predict if a subject would require supplemental opioids and assign a Pederson score for each tooth to be extracted to give a cumulative difficulty score. Sensitivity, specificity, positive and negative predictive values of surgeons’ predictions and the relationship between anticipated difficulty and need for supplemental opioids was evaluated.

Pederson Difficulty Index scores were similar between patients who used supplemental opioids (19.88 ± 6.368) and those who did not (21.18 ± 3.801; P = .285). Surgeon correctness between patients who used supplemental opioids (34.78% ± 13.23%) and those who did not (45.05% ± 9.72%) were comparable with a p value of .2562. Validity tests revealed that the four surgeon predictions of opioid need revealed low sensitivity (mean = 34.78% ± 13.23%) and specificity (mean = 45.05% ± 9.722%). The positive predictive value ranged from 7.3% to 14.6%, while the negative predictive value ranged from 70.6% to 83.3%. The 4 participating surgeons correctly anticipated need or no need of opioids 42.7% ± 5.53% of the time with no difference between opioid use vs no opioid use cohorts. When surgeon prediction of outpatient opioid need was scaled 1-5 for strongly disagree to strongly agree, the mean for those who did (2.906 ± 0.917) and did not require opioids (3.071 ± 0.840, P = .487) was comparable. Surgeon predictions were within 1 degree of agreement in 11/16 (68.8%) of subjects who required supplemental opioids and in 44/70 (62.9%) of subjects who did not require supplemental opioids (P = .658). Pederson Score and Surgeon Prediction were significantly correlated with a coefficient of 0.346 (P = .00111). Further stratification of subjects by sex and age greater or less than 26 years of age did not improve accuracy.

From this data, surgeon prediction based on panoramic radiographs and Pederson Difficulty Index proved ineffective at anticipating which patients would require outpatient opioids for third molar post-operative pain management. Because these methods are unreliable, the exploration of more accurate predictors is warranted to improve pain management, reduce opioid exposure, and minimize the prescribed opioids that go unused.

This study highlights a surgeon’s constant effort to balance the risks of opioids with optimizing pain control after surgery and that basing this judgement off of radiographic predictors is not as reliable as some would hope. Our results emphasize the need to develop more accurate tools to aid in anticipating this need.

Miroshnychenko A, Ibrahim S, Azab M, et al. Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis. J Dent Res. 2023;102(4):391-401. doi:10.1177/00220345221139230
- Carrasco-Labra A, Polk DE, Urquhart O, et al. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. The Journal of the American Dental Association. 2024;155(2):102-117.e9. doi:10.1016/j.adaj.2023.10.009
- White Paper on Third Molar Data. American Association of Oral and Maxillofacial Surgeons. March, 2017. Figure 1 Table 1- Validity Figure 5