Thirty-eight households were mailed a notification letter, of which one had an inaccurate mailing address. Thirty-seven households entered phone follow-up. Of these, ten were unreachable and four guardians declined participating, five were ineligible (e.g., patient turned 18 years old, parent was dental care provider at HealthPartners). Eighteen guardians consented, but in three instances, the patient was unavailable or unreachable within the maximum number of call attempts or within 30-days post extraction. Fifteen dyads completed an interview. The patient demographics are summarized in Table 1. Adolescents and their parents described experiences in terms of those surrounding the extraction experience itself, which were largely procedural, and behaviors post-extraction, centered on recovery from the procedure, including pain management.
Sources of Information
Adolescents identified parents and other family members, their dental providers, and their peers as sources of information for what to expect during and after the dental procedure, with parents providing similar perspectives. Adolescents who received information from peers described it as more general information regarding the procedure and recovery (e.g., “their cheeks kind of swollen after the extraction”, “be careful and cautious about eating”). Parents and other family members, including older siblings, were identified as sources providing more detailed information, sometimes with a cautionary tale. As was the case with peers, this information was usually based on a parent’s/older siblings’ own experiences, having gone through the same procedure or another surgery-related experience requiring sedation. Dentists and oral surgeons provided information on both the procedure and what to do post-extraction to aid in recovery, and they shared this information with parents and adolescents both before the procedure and again right after the procedure, verbally and through handouts and post-operative information sheets. While the information shared by peers was taken as a way to minimize or generalize the dental extraction experiences, caregivers often warned the adolescents of negative outcomes, such as difficulty with anesthesia, high levels of pain, etc. Information shared by dental providers was highly tactical and was not described as conveying the emotional resonance of the caregivers’ information.
Pain Management Behaviors by Adolescents and their Caregivers
Adolescents and parents alike largely described shared decision-making, where patients and parents discussed pain management options together and a plan was reached that was agreeable to both. Parents largely assisted with organizing the placement and the timing of taking the medications or reminding the child to “stay ahead” of the pain after a plan had been decided upon. In one extreme example a parent (with a health care background) encouraged their child to take an opioid medication, instructing the child to set an alarm to self-medicate in the middle of the night rather than waking up in pain and losing the rest necessary to recuperate. This parent provided a high degree of guidance and control over the pain management process; whereas, the other parents largely gave reminders and support but let their child decide when or if they needed more pain medication and what kind to take.
Two-thirds of the adolescents (n=10) administered their own non-opioid medication. Adolescents and parents explained that this was largely the result of logistical issues (e.g., the parent or adolescent being at work and unable to rely on one another) and the adolescent being responsible enough to handle the dosing. Parents often provided reminders and other structure in the days following the extraction, such as putting the medications on their bedside. Eighty percent of parents (n=12) reported keeping the opioid prescription secured. By doing this, they were able to control when and how it was administered. Input from the adolescent about pain intensity was the most common driver for when opioid medications were given.
The main reason for allowing adolescents to self-medicate was that only they could determine how bad the pain was and whether they needed another dose of pain medication. The following quotes (from un-matched parent and child interviews) illustrate this point.
“Interviewer: How would you say you felt about how much input your child had regarding managing their pain? Parent: I think she had enough input. She was really the driver of it. I mean, whatever she needed, we supported her on what she needed for it.”
“Interviewer: And did you remember discussing with your parents whether or not to take those [opioid] medications? Adolescent: Yeah. Interviewer: What went on there? In that conversation? Adolescent: That if I needed them [opioid medications], if I needed to take it because of the pain, I could take them. But I never really went through that much pain, so I just never took them.”
Parents largely deferred to their child when it came to pain management behaviors and, despite not wanting them to be unnecessarily in pain, parents left it up to their adolescents’ discretion.
The Use of Medications
All participants reported receiving guidance from their dental provider regarding the use of medications for pain management, in addition to receiving antibiotics to assist with the post-operative recovery process. Recommended medications included both over-the-counter products (e.g., ibuprofen, acetaminophen) and prescription opioids (e.g., Vicodin, Tylenol with codeine), but few participants could specifically name the opioid they were given. As one adolescent recalled, “And there was one, but it was for in case I had major pain. It was an opioid. Yeah, I forgot what it was called, but it was in case I had some major pain going on.” Either the parent, adolescent, or both from each dyad reported being given an opioid for pain management from their dental provider. While no one reported not filling their opioid prescription, many reported not taking them at all or only taking a couple pills in the first few days following the extraction. Since the prescriptions were to take the medication “as needed” they were taken as prescribed. One parent described the instructions as follows:
“Interviewer: And do you remember how the dentist or oral surgeon sort of advised you about how to manage the pain after surgery? Parent: Yeah, just like Ibuprofen ... you know ice, and [they] gave him a couple of ... again I don't know if it Percocet, Vicodin- Hydrocodone. [They] gave him four. I think of the four he only ended up taking two. One each night, for two nights, just so he could sleep. Interviewer: Mm-hmm (affirmative). Parent: But otherwise, he managed the pain without anything else and within- within a week, well, maybe five days, not even, he was feeling pretty good.”
Another parent described both the medications and timing similarly:
“Interviewer: How did the dentist or oral surgeon advise you or your child about managing the pain after the surgery? Parent: Well, [they] just said just use Tylenol, especially the first few days or whatever because her [inaudible], and then [they] also gave out some heavier dose of pain medicine, and [they] says, ‘Well, you might want to save these until a few days later when the gas wears off and stuff and actually she's feeling the pain,’ which she didn't need to use at all, so that was a good thing, but yeah, they explained both medications to me.”
Despite all participants indicating they had been given opioids to take for pain management as needed, not all participants were aware of being given clear instructions about disposal of unused medications. Some participants were given guidance by pharmacists upon filling the prescription, while others were not. Some participants asked about disposal on their own. No participants reported receiving direction on disposal of unused medications from their dentist or oral surgeon.