Nonopioid remedies are changing the landscape in dentistry.
Naturally, dentists want to ensure that patients have the most pain-free experience possible when receiving dental care. Traditionally, that has meant pulling out the prescription pad.
That’s not true anymore. The opioid epidemic has forever changed the way clinicians approach pain management. Opioid overdoses led to the deaths of nearly 50,000 individuals in the United States in 2019, a 600% increase since 1999. Of those 50,000 overdose deaths, more than 14,000 were confirmed to have been caused directly by prescription opioids—a number that doesn’t take into account individuals who became addicted to prescription drugs and then transitioned to heroin or synthetic opioids.1
These numbers are staggering and frightening to both clinicians and patients. Although dentists are just 1 piece in the opioid-prescription puzzle, they play an important role in the opioid epidemic. Dentists are the top prescribers of opioid prescriptions (12%) after family physicians (15%). Historically, they have often written opioid prescriptions before considering other options.2
“While dentistry doesn’t contribute the largest number of opioid-based narcotics, I think dentists are interested in continuing to reduce the use of opioid-based prescription medication,” says Debbie Durako, director of StellaLife, Inc., a biotech company with all-natural products. “As awareness of how dangerous these drugs can be has grown, and the crisis of people dying from opioid addiction and overdoses has skyrocketed, clinicians feel it’s better just not to dispense that at all, so they’re turning to alternatives.”
This awareness is reflected in the decrease in opioid prescriptions coming from dental practitioners. In 2018, the American Dental Association became the first professional health organization to mandate limits on opioid prescriptions and publicly urge clinicians to consider alternative options as the first line of defense in pain management—and dentists listened. From 2014 to 2019, dentists wrote nearly half a million fewer opioid prescriptions.3 To find a suitable alternative, dentists have been exploring numerous options—from nonsteroidal anti-inflammatory drugs (NSAIDs) to natural remedies that are flooding the market—with promising results.
Taking Action With NSAIDS
NSAIDs are a primary group of analgesic drugs commonly used in dentistry. Treatment of pain can most effectively be achieved through analgesic drug combinations. The analgesic efficacy of these combinations is often underestimated; however, perhaps surprisingly, NSAIDs have been found to be more efficient than opioids at reducing mild to moderate pain. Working in concert, NSAIDs (such as ibuprofen) and acetaminophen minimize pain by reducing inflammation at the site and blocking the transmission of pain signals. This combination is particularly effective because it blocks pain at both ends of the nociceptive pathway.4
“What’s particularly scary about opioids is how fast addiction can set in,” Durako says. “So, it’s important to have some alternatives. We know so much more now about NSAIDs and the acetaminophen combo; there are studies on them and how they control pain better than codeine. So there are definitely safer options out there for the patient, both chemical and natural.”
Although NSAIDs have been found to be effective at treating mild to moderate pain, opioids can be considered for moderate to severe pain. Because NSAIDs have an effectiveness ceiling, they are not able to manage more acute pain. In contrast, opioids do not have an analgesic ceiling.5 However, investigators caution that dentists should start conservatively when it comes to pain management and that judicious opioid-prescribing interventions should be employed. One recent study found that between 1 in 4 and 1 in 2 opioids prescribed to adult dental patients were overprescribed.6
Finding pain-management solutions without opioids is new to many dentists, with many looking elsewhere for solutions or options to pair with NSAIDs pain-management treatment. One place clinicians are looking is the natural world.
The Natural Approach
Botanicals and herbs have long been recognized as options for healing, inflammation reduction, and pain management. Herbal extracts have been used in the oral biome for centuries—perhaps millennia—as anti-inflammatories, antiseptics, antimicrobials, antifungals, antibacterials, and analgesics, and to control microbial plaque.7 Ancient Egyptians used anise seeds and frankincense to provide relief from toothaches, and pre-colonial Native Americans turned to witch hazel to soothe sore gums. Garlic, marjoram, ginger, and other spices have all been hailed for their healing properties for oral ailments.8
“Most of our medications are chemically derived, but they started with plants, and then we chemically duplicated the chemical composition,” Durako says. “And so, we can go back in history, and you can see for centuries that certain particular plants definitely had efficacy in managing pain or treating symptoms. It makes a very good statement on behalf of our natural plants and minerals in our environment. Now, we’re turning back to that.”
Although there may not be spices lining the shelves of modern dental operatories (and myrrh and nettle root are probably in short supply in most practices), many of these natural ingredients are making a resurgence in current remedies. As the popularity of clean living and the subsequent concerns about additives and chemicals increase, patients and doctors are turning to holistic remedies.
“Our community is more interested in clean living,” Durako says. “We’ve just seen so much of that more chemical-free, clean-living type of lifestyle. Now dentists have combined that concept with the fact that we want to make options for our patients that are healthier for them and have less risk.”
The growth has been expansive and quick. The alternative medicine industry, which includes botanical and natural remedies, homeopathy, and mind and body healing, is expected to reach $404.66 billion
“We’ve personally seen a big shift since our introduction in the dental community in 2019,” says Waylon Ford, chief operating officer of Kingdom Harvest, a company based in Hendersonville, North Carolina, that produces hemp extract and cannabidiol (CBD) oil for use in dental practices as well as personal use. “We’ve found that one of the No. 1 concerns in dental offices is that they want to give the clients the best experience possible. There is a rising need for a more natural method to manage pain, stress, anxiety, and discomfort.”
To meet these needs, a bevy of companies emerged to provide natural remedies and opioid-free options for pain management. Catering directly to patients, brands such as Dr. Brite offer oral healing sprays that are vegan, plant based, and paraben and sulfate free and are said to reduce pain and discomfort through blends of tea tree and therapeutic essential oils. Dental Herb Company offers a topical gel called PerioSpot® that is made with herbs and essential oils and designed to reduce gum inflammation through TrulyNatural® ingredients. StellaLife has a 3-pronged approach to pain management: tackling microbes, fighting inflammation, and healing wounds all at once through its VEGA® Oral Care Recovery Kit, which includes a rinse, spray, and gel.
VEGA’s natural solution was formulated as adjunctive therapy to reduce the need for opioids and steroids for pre- and postsurgical dental treatment. The kit’s antimicrobial rinse, sublingual pain-relief spray, and topical gel are said to improve recovery, reduce discomfort through the reduction of swelling and bruising, and provide fast-acting relief for everything from lichen planus and mucositis to postsurgical care, canker sores, and mouth ulcers. Patients can use the kit before and after clinical treatment and at home for daily use.
“VEGA is an antimicrobial, so we are able to reduce the anaerobic bacteria levels by 50% for almost 4 hours,” Durako explains. “The other piece of the puzzle here is the anti-inflammatory effects of the product. It’s the synergy of the 16 different active ingredients that magnificently, rapidly wound heal. If you can control the inflammation, you have a really good shot of controlling pain. VEGA actually stimulates fibroblasts, allowing patients to heal faster. So, not only are you reducing inflammation and speeding up healing, you’re providing effective pain management—all done in a natural way.”
These natural approaches are becoming more popular with doctors and patients alike.
“Coming from a time period of overly prescribed medications, I feel that we are seeing a rise in people that are wanting to change to a more natural, holistic method that is better for the body and environment,” Ford says. And one such approach, offered by Kingdom Harvest, comes in the form of CBD.
The CBD Solution
Cannabinoids are nothing new to pain management. Investigators have found evidence of cannabinoid use dating back to 5000 years ago in Romania, and cannabis, first mentioned in the United States Pharmacopeia in 1850, was widely used for medicinal purposes in the 19th and into the early 20th centuries.10,11 However, the Marijuana Tax Act of 1937 enacted restrictions on cannabis use, and it wasn’t until 1996 that California became the first state to legalize access to cannabis for medicinal purposes.12
Although CBD is extracted from the buds and flowers of hemp or marijuana plants, it does not produce the high commonly associated with marijuana use (which stems from tetrahydrocannabinol [THC], a different chemical in the plants). Hemp and marijuana plants are different varieties of cannabis plants. Although marijuana plants have a high THC concentration (defined by law as more than 0.3%, but more often approximately 5% to 30%), hemp plants have less than 0.3% THC and a high concentration of CBD—a critical ingredient for hemp extracts, making them the first choice for CBD extracts.
“CBD opened the door to an entirely new way for people to manage their pain and/or discomfort and bring a natural balance to their endocannabinoid system,” Ford says. “The education of the endocannabinoid system has been a great help as people learn that it is the umbrella system to our entire body.”
CBD’s applications in the dental industry are numerous. In addition to calming and relaxing patients, CBD can minimize pain and discomfort while also fighting inflammation. CBD can be used preprocedure (either at home or in the dental practice) to reduce anxiety and lower inflammation risks and postprocedure for pain management and to lower infection risks. This can help lessen the need for pharmaceutical pain management such as opioids and speed up recovery times.
“Aside from being a natural and organic method supplied to us by Mother Nature, it is also not addictive and helps fight and manage our entire body, not just 1 ailment,” Ford says. “CBD helps lower blood pressure, preemptively fights the inflammation that will be caused by the procedure, and allows the clients to have a calming and relaxing experience. Plus, studies have been shown that CBD also helps as a preventative measure for gum disease, tooth decay, TMJ, and more.”
Kingdom Harvest in particular saw the benefits for the dental industry and made its introduction to the dental community at the 150th Hinman Dental Society Annual Meeting in 2019. The company offers a full package for dental practices, which includes a digital pipette distribution system, disposable pipettes, and two 30-mL and twenty-four 15-mL bottles of Kingdom Harvest Whole-Spectrum Hemp Extract & CBD Oil, as well as brochures and marketing materials.
“I feel that CBD and other cannabinoids will be playing a huge role in the pain-management field again,” Ford says. “At one time, hemp-derived cannabinoids were in over 90% of all medications. We are simply bringing hemp back to the dental industry.”
A Changing Landscape
As research progresses and more natural options become available, the way dentists approach pain management is rapidly shifting. Breakthroughs in technology that simplify potentially painful treatment—such as lasers—coupled with the development of a wide range of nonopioid pain-management options spell increased comfort for patients down the road. Whether it be through NSAIDs, hemp products, essential oils, or other pain-free treatments, opioid alternatives are here to stay.
“I really believe natural remedies are changing the industry,” Durako says. “I think we are going to have more natural options to prepare our patients for dental procedures and to treat pain afterward. There’s a lot of research coming down the pipeline on pain-control methods that won’t be addictive and ways we can reduce incidences of disease through natural processes—even as simple as nutrition. The future is exciting as we learn more and are able to provide better, safer care to patients.”
In the end, better, safer care for all patients is the bottom line.
“Probably the biggest vision of ours is to save lives through intelligent healing,” Durako says. “The applications and spectrum of natural products are really wide [for treating] so many types of oral conditions beyond the surgical patient. Opioid-free pain-management methods will benefit all our patients.”