Dentistry and the opioid crisis: the wisdom tooth problem

Dental committees reach for this because it is their profession’s clearest case of iatrogenic harm from an ordinary, well-meant habit. Nobody set out to start anyone on opioids. Dentists prescribed what they had been taught to prescribe, for real pain, in good faith — and a measurable number of young people were harmed as a result.

Here is the version worth holding. This is not a story about bad dentists. It is a story about what happens when a routine is inherited rather than examined, and about how long it takes evidence to change a habit that everyone believes is kind. That framing is what a panel is listening for, because the same failure mode will be available to you in whatever you practise.

Three things converged. The procedure. Removal of third molars is among the most common surgical procedures performed on young people in the United States, frequently all four at once, frequently under sedation, and frequently in otherwise healthy patients in their late teens. The pain. It is genuinely painful for two or three days, peaking after the local anaesthetic wears off — precisely the window in which an anxious patient telephones out of hours. The habit. Prescribing a short course of an opioid combination was standard teaching for decades, and a prescription written on the day removed the risk of a distressed call at the weekend.

The age is what made it dangerous. First opioid exposure in adolescence is associated with a higher likelihood of later misuse than exposure in adulthood, and studies of opioid-naive young patients who received a dental opioid found a meaningful proportion still using at a year. The leftovers mattered too: a course prescribed for five days when two were needed left tablets in a bathroom cabinet, and household members were found to be at raised risk of misuse — the diversion problem that made a single prescription a family exposure rather than an individual one.

The finding that changed practice is straightforward and worth being able to state precisely. For acute post-operative dental pain, a combination of ibuprofen — a non-steroidal anti-inflammatory acting on the inflammatory driver of the pain — and paracetamol, which works by a different mechanism, provides analgesia equal to or better than opioid combinations in most patients, with fewer adverse effects and no dependence risk. Two drugs acting on different pathways beat one that acts centrally and sedates.

That does not mean opioids have no place. A patient who cannot take non-steroidals — significant renal impairment, certain gastrointestinal disease, some anticoagulation situations — needs an alternative. Some surgical cases genuinely exceed what the combination controls. The current position is that an opioid should be a considered exception with the smallest effective quantity for the shortest period, not a default written alongside the extraction note.

The undertreatment risk deserves naming, because the pendulum can swing too far. Pain that is real and inadequately controlled is itself a harm, and there is evidence that some patient groups — including Black patients — have historically been undertreated for pain in emergency and dental settings. A candidate who says "never prescribe opioids" has replaced one unexamined rule with another.

The generalisable point, and the one that earns marks, is about how the harm happened. Nobody was negligent in the ordinary sense. Dentists prescribed the drug they were taught to prescribe, for pain that was real, to patients who were grateful. The harm was invisible at the level of the individual consultation and only appeared in population data — which is precisely the kind of harm a conscientious clinician cannot detect by paying attention to their own patients.

That has three implications a panel will recognise. First, routine deserves periodic examination, because "this is how we do it" is not a clinical justification. Second, population-level evidence has to be able to overturn individual clinical impression, which is uncomfortable because your own patients did seem fine. Third, the profession corrected itself — through guidelines, education requirements, monitoring programmes and state limits — which is the argument for self-regulation actually working, and it is fair to say so.

This arrives in three shapes. The direct one: "What role has dentistry played in the opioid crisis?" The scenario one: a patient asks specifically for something stronger after an extraction. And the disguised one — "Tell me about a time medicine got something wrong" or a question about evidence-based practice.

For the direct question, give the third molar mechanism and then the correction. For the scenario, explain the evidence, offer the combination, and know when an opioid is genuinely indicated. For the disguised question, this is one of the best available answers because the profession fixed it.

Start with the ADA’s statement and policy on opioid prescribing, then its clinical practice guideline on managing acute dental pain, which sets out the ibuprofen and paracetamol recommendation with the evidence behind it. The CDC’s opioid prescribing guidance gives the wider context, and any of the studies of persistent use in opioid-naive dental patients is worth reading in the original for its methods.

Two pieces here sit beside this one. How a dentist is trained in America explains where prescribing habits are formed, and silver diamine fluoride is the other case of dentistry rethinking a routine. For the ethics framework, see our guide to the four pillars.