For older teenagers and young adults, the extraction of wisdom teeth is a painful rite of passage. A new study suggests that it's probably made more perilous by the narcotic pain pills that patients frequently carry home after the common surgical procedure.
The study offers new evidence of how readily – and innocently – a potentially fatal addiction to opioids can take hold. It also shows how important it is that dentists rethink their approach to treating their patients' postoperative discomfort.
In a group of about 15,000 people whose first prescriptions for opioid painkillers came from a dentist or dental surgeon, researchers found that about 7 percent filled another opioid prescription 90 to 365 days later.
And in the year after their dental procedures, nearly 6 percent of patients who left their dentist's offices prescriptions for opioids had a "health care encounter" – a hospitalization or trip to the emergency room, a physician consultation, or a session with an addiction specialist – in which a diagnosis of opioid abuse was documented.
That's more than 10 times the rate at which a comparison group of patients who did not receive prescriptions for opioid painkillers got that diagnosis. Patients in both groups were 16 to 25 years old, and all were treated by dentists in 2015. Researchers then were able to track the patients for at least a year.
Compared with the study's boys and young men, girls and young women were more likely to continue using narcotic pain relievers after getting their wisdom teeth out, and they were much more likely to abuse the drugs.
The typical prescription capable of setting such havoc into motion was a pack of about 20 pills of an opioid narcotic such as OxyContin, Vicodin or Percocet.
Published this week in the journal JAMA Internal Medicine, the research comes as opioid drugs are killing 115 Americans a day. Although fatalities are also caused by street drugs such as heroin and, increasingly, synthetic opioids such as fentanyl, as many as 80 percent of those addicted to heroin say they started by abusing medications that were prescribed for legitimate purposes.
That in turn has called attention to the medical profession's prescribing practices and its role in the public health crisis. In 2016, as the epidemic of overdose deaths continued its steep rise, those in the medical and dental professions prescribed enough painkillers to medicate every American daily for close to a month.
Although many of the pills are prescribed to manage the agony of patients with excruciating pain, physicians and dentists still prescribe opioids to patients whose pain could be treated more safely, and just as effectively, with nonnarcotic drugs.
The new study also calls into question the wisdom of routinely extracting wisdom teeth, which tend to push through rear-most gums in late adolescence or early adulthood, often crowding other teeth or becoming impacted.
Study author Alan R. Schroeder, a Stanford University pediatrician with an interest in "safely doing less," said the benefits of wisdom-tooth extraction have not been rigorously studied or demonstrated. Nor, he said, have its risks.
Studying the risk of opioid addiction or abuse, at least, seemed like a good place to start, he said.
The surgical removal of wisdom teeth comes with such potential downsides as dry sockets, gum pain and nerve damage, and risks associated with the anesthesia used during those procedures.
And then there are the drugs. Dental surgeons have been among the most liberal prescribers of opioid painkillers, and they're also heavy prescribers of antibiotics. Those medications can come with side effects, and over-prescription is believed to foster the rise of antibiotic-resistant infections.
Schroeder said the dearth of research about wisdom-tooth extraction makes its frequency hard to judge. And that, in turn, forced Schroeder and his co-authors to make an assumption in their study.
Dental insurance databases are scarce and many wisdom tooth extractions are paid for out of pocket. But given the age of most of the patients leaving a dentist's office with an opioid prescription, Schroeder and his co-authors figured that the most likely cause was wisdom-tooth surgery (a third-molar extraction in dental parlance). The authors' conclusion that opiate abuse is a possible risk of wisdom-tooth removal rests on this assumption.
But when you consider how many young people have their wisdom teeth removed, and how routinely dentists send their patients home with prescriptions for narcotic pain relief, the implications are pretty alarming.
An unpublished 1999 study by the American Dental Assn. and cited by the authors estimated that there are about 5 million such extractions a year. By 2009, another study had concluded that dentists were the leading source of opioid prescriptions for children and adolescents ages 10 to 19, accounting for close to one-third of opioid prescriptions in this age group.
The American Dental Association promised that its members will reduce their opioid prescribing. In a statement released in March, association president Joseph P. Crowley called on dentists to "double down on their efforts" to write fewer prescriptions for opioids to treat dental pain, to lower the doses that are prescribed, and to shorten the duration of prescriptions – all measures known to reduce addiction risk. The association has also supported state legislation to limit opioid prescriptions' dosage and duration, and to track medical professionals' prescribing practices.
"The dental profession deserves credit for trying to tackle this," Schroeder said. "It's easy to point the finger at dentists – over time, they have contributed a fair amount of the opioid exposure. But they really have made efforts to limit that in recent years."