Tramadol was approved by the U.S. Food and Drug Administration in March 1995 as a noncontrolled substance but was reclassified in 2014 as a schedule IV medication under the Controlled Substances Act due to concerns about misuse. It is commonly prescribed for moderate to severe pain, offering relief similar to 60 mg of codeine, though it is often less effective than combination therapies with nonsteroidal anti-inflammatories or codeine plus acetaminophen or aspirin.
Despite its effectiveness in managing pain, Tramadol poses significant risks, especially in dental settings, because of its potential for misuse and adverse effects, such as respiratory depression. Careful assessment is crucial when prescribing Tramadol for postoperative pain to ensure patient safety.
Patient selection and dosing considerations
Tramadol should be prescribed with caution, tailoring the dose to the patient's pain severity, previous treatments, and risk of addiction or misuse. The maximum allowable dose is 400 mg per day, and it should be given at the lowest effective dose for the shortest duration possible. Dentists may consider prescribing naloxone as a precaution for potential overdose.
Tramadol is not recommended for children under 18, particularly after tonsillectomy or adenoidectomy, and should be avoided during pregnancy or breastfeeding due to risks for the baby. For patients dependent on opioids, tramadol should be tapered gradually to prevent withdrawal effects.
Side effects
Tramadol is associated with a variety of side effects, including common ones like constipation, nausea, sleepiness, vomiting, tiredness, headache, dizziness, and abdominal pain. More serious risks include respiratory depression, seizures, and the potential for addiction or misuse. Prolonged use of tramadol may lead to dependence or tolerance, and in certain cases, it can cause opioid-induced hyperalgesia.
Special considerations in dentistry
1. Dry mouth (xerostomia): Tramadol can cause dry mouth, raising the risk of dental caries, plaque buildup, and periodontal disease.
2. Increased risk of oral infections: When combined with central nervous system (CNS) depressants like benzodiazepines or alcohol, tramadol can suppress the immune system, increasing the likelihood of oral infections and delayed healing of surgical sites.
3. Drug interactions: Tramadol has interactions with many medications commonly prescribed in dentistry, and certain drug combinations with tramadol can lead to life-threatening situations. It's important to check for drug interactions using trusted resources like the Digital Drug Handbook.
- Antifungals like fluconazole, as well as antibiotics such as azithromycin, ciprofloxacin, clarithromycin, or metronidazole, can raise tramadol levels and increase the risk of QT prolongation and cardiac arrhythmias.
- Avoid prescribing erythromycin, as this combination may raise tramadol levels and decrease erythromycin efficacy. It may also increase the risk of CNS and respiratory depression, diminished psychomotor function, seizures, and serotonin syndrome.
- Combining tramadol with local anesthetics such as lidocaine may elevate the risk of seizures and hypotension.
- Combining tramadol with benzodiazepines or antiseizure medications used for chronic pain such as carbamazepine may significantly heighten the risk of severe CNS and respiratory depression, impaired motor function, hypotension, and seizures.
4. Serotonin syndrome: Combining tramadol with muscle relaxants like cyclobenzaprine increases the risk of serotonin syndrome. Additionally, grapefruit and St. John's wort should be avoided, as they can exacerbate this risk. Serotonin syndrome may cause symptoms such as jaw clenching and facial muscle issues, which can impact dental restorations and orthodontic appliances. Given these risks, dentists may want to avoid combining these medications.
5. Delayed healing and complications: Tramadol's CNS effects and interactions with other sedatives may slow recovery after dental surgeries, leading to complications like dry socket or infections.
6. Sedation and impaired coordination: After prescribing, provide fall precautions to the patient or their companion. Patients may need to return for follow-up visits, such as a dry socket, postoperative check, or suture check while still taking pain medications like tramadol. Be aware that tramadol can cause drowsiness and impair motor skills, increasing the risk of falls. To mitigate this risk, when the patient (especially if they are older) is ready to leave the chair, place them in an upright position for a few minutes to allow their blood pressure to stabilize and assist them when exiting the dental chair and walking to the front office.
Harnessing technology to manage tramadol safety
Tramadol is an effective medication for managing pain, but its use in dental practice demands careful attention to potential side effects and drug interactions. As dentists, staying informed about these factors is essential for delivering optimal patient care and ensuring safe, effective treatment. The MedAssent DDS Digital Drug Handbook is an invaluable resource for navigating tramadol's complexities, offering detailed, dentistry-specific insights on drug interactions and patient management. Explore their tools to enhance your practice and improve patient outcomes.
Barbara Madej, RPh, is a licensed pharmacist who has dedicated her life to serving her home country of Canada, as well as her new home of Los Angeles, after receiving her degree in pharmacy from the University of Saskatchewan. Madej co-founded MedAssent Rx in 2015, drawing from her decades of experience in pharmacy and putting her passion to action.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
