Opioids in the Dentist’s Office

The Major Risk of Minor Procedures

If you’re a young adult, chances are you’ve either already had your wisdom teeth extracted or removal has been recommended by your dentist.   In the U.S., more than 5 million persons, most under 35 years of age, undergo this “minor” surgical procedure every year. (1)  Most have no symptoms and the procedure is usually done to prevent subsequent failure of the teeth to fully erupt risking infection of the surrounding gums or to prevent crowding of the other teeth.   Removal has long been considered a relatively benign procedure - almost a “right of passage” for adolescents and young adults - with a couple days of swelling, soreness and time off from work or school the principal negatives.  A recent study reports a far more serious and sinister complication: opioid use disorder (OUD).  (2)  

The study by the Stanford Pediatrics Department compared 29,791 persons, average age 21.8 years, who received a first-time opioid prescription from a dental clinician with a matched non-opioid exposed group.  Though the expectation was that the opioid prescription was for short-term post procedure pain relief, the study found that 1021 opioid-treated patients (6.9%) received additional opioid prescriptions 90 to 365 days after the procedure.  866 persons (5.8%) were treated for an opioid-abuse related diagnosis. The most common drugs prescribed were hydrocodone/acetaminophen (Vicodin) and oxycodone/acetaminophen (Percocet).   While some have suggested reducing the number of pills in an initial opioid prescription for acute pain to reduce risk of longer term use and OUD, the risk of persistent opioid use wasn’t related to the number of pills in the original prescription in this study.  In sum, a “low risk” dental procedure led to potentially lethal illness - OUD - in at least 6% of patients.

Dentists are the most common provider of opioid prescriptions for children and adolescents aged 10-19 with third molar (wisdom teeth) extraction likely the most common indication. (3)  The Stanford study found dentists accounted for 30.6% of all opioid prescriptions in persons aged 16-25 years.  

The risk of persistent opioid use and OUD after minor surgery isn’t confined to the dentist office.  A recent study evaluated more than 36,000 opioid-naive patients undergoing minor (80%) or major (20%) surgery who received an opioid prescription for persistent use at 90-180 days post procedure.  The rate of new, persistent opioid use (i.e., risk of OUD) was similar in both groups ranging from 5.9-6.5%.    Risk factors for persistent opioid use included tobacco use, prior alcohol and substance use disorders, mood disorders, anxiety, and preoperative pain disorders.  The authors concluded prolonged use was not entirely due to surgical pain.   If more than 50 million “minor” surgeries are done in ambulatory surgery centers (ASCs) annually in the U.S., up to 3 million patients could be at risk of persistent opioid use and OUD.   The biggest unanticipated and “silent” risk of minor surgery may be the opioid prescription provided for postoperative pain!

Companies can support employees considering surgery (dental or medical) and who may also be struggling with SUD or other behavioral health challenges:

• Provide education about the risks of opioid pain management strategies, empowering them to discuss their preferences and plans with their medical or dental provider.  Tools such as Operation Lighthouse/Shatterproof can provide confidential, quality guidance.

• Anxiety, depression, alcohol and substance use disorders all dramatically increase risk of poor surgical outcomes.  Leaders should encourage a stigma-free workplace, encouraging employees to address these issues before undertaking elective surgery.

• Leaders should maintain frequent contact with employees who have had a surgical procedure and facilitate return to work as soon as medically cleared.

1. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Pub Health.  2007; 97:1554-1559.

2. Schroeder AR, et al. Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse. JAMA Intern Med 2019; 179(2): 145-152.

3. Volkow ND, et al. Characteristics of opioid prescriptions in 2009. JAMA 2011; 305(13): 1299-1301.

4. Brummett CM, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017; 152(6):e170504.

Dan Mazanec, MD, FACP