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In July, a group of state attorneys general announced a settlement with the drugmaker Johnson & Johnson and three of the nation’s largest pharmaceutical distributors to resolve claims that their actions helped fuel the opioid epidemic. The main lawsuits accused distributors—McKesson, Cardinal Health, and AmerisourceBergen—of facilitating the flow of massive amounts of opioids into communities and Johnson & Johnson of deceptive opioid marketing. The companies denied any wrongdoing.
Meanwhile, the opioid crisis rages on. Overdose deaths reached record highs in 2020—up about 31 percent over the previous year, according to the Centers for Disease Control and Prevention (CDC).
One surprising source of those drugs? The dentist.
Overdose rates were two and a half times higher in people who filled an opioid prescription after a dental procedure than in those who didn’t according to a recent study published in the American Journal of Preventive Medicine.
Researchers at the University of Michigan analyzed medical records of teens and adults who underwent a dental procedure such as having their wisdom teeth taken out between 2011 and 2018. Of the 8.5 million procedures analyzed, patients filled a prescription for an opioid such as Vicodin or Oxycontin in nearly 27 percent of cases.
In that group, the overdose rate was 5.8 per every 10,000 patients compared with 2.2 per 10,000 procedures among patients who didn’t fill an opioid prescription.
Overdose rates were also higher among the family members of those filling an opioid prescription according to the team’s separate analysis of about 3.5 medical records.
The study authors estimate that l,700 fewer overdoses would happen each year in the US if dentists did not prescribe opioids.
Opioid prescribing by dentists has declined dramatically over the last two decades, including in the three years since the most recent data from the University of Michigan study, said Raymond Dionne, PhD, a member of the American Dental Association’s Council on Scientific Affairs. “Twenty years ago, about 15 percent of all the prescriptions for opioids in the US, were being written by dentists,” he says. “Now it’s down to maybe a third of that.”
But, Dionne, who specializes in pain research, says that there is still room for improvement.
The good news is that dentists can recommend safer ways to get relief. A body of research shows that over-the-counter pain relievers work just as well—or better— than opioids for most people, with far fewer side effects.
Too Little Relief, Too Many Side Effects
It’s a myth that opioid pain relievers are more potent than OTC products, Dionne says. “People can feel like they are not getting the most powerful pain reliever if they don’t get something with an opiate, but it can be the opposite.” he says.
Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, and generic) and naproxen (Aleve and generic) work particularly well against dental pain because they block the enzyme that causes your gums to become red and swollen, says Paul A. Moore, PhD, a professor at the University of Pittsburgh School of Dental Medicine. Acetaminophen (Tylenol and generic) work through a different mechanism to reduce your perception of pain, he says.
The combination of an NSAID and acetaminophen works well against even moderate to severe pain in people who have had their wisdom teeth removed—better, in fact, than an opioid for most people. That’s according to a comprehensive research review by Moore and colleagues that was published in the Journal of the American Dental Association in 2018.
Another advantage to OTC pain relievers is that, in general, they cause far fewer side effects than narcotic pain meds. Prescription opioids commonly cause nausea, constipation, drowsiness, and a fuzzy-headed feeling. In addition, taking the drugs longer term or in higher doses carries more serious risks, including addiction, overdose, and even death.
Making a Plan for Dental-Pain Relief
People undergoing any kind of dental surgery should ask what treatments are available and communicate their preferences for pain control when making a plan with their dentist or oral surgeon, Dionne says.
Make sure you’ve provided a thorough medical history so that your doctor can recommend pain relievers that are safest for you. Most people who take blood thinners or who have advanced kidney disease should avoid NSAIDs, for example.
It’s important to know that taking too much of any kind of pain medication—even OTC products—isn’t safe. So, get written instructions for how much of each type of medication to take and how often to take it.
Start with steps to reduce dental pain immediately after your procedure, when it’s likely to be most severe, says Dionne.
For example, your dentist can use a long-acting local anesthetic to keep you numb longer and inject a steroid to reduce swelling. You can apply cool packs when you get home and also take an NSAID before the anesthetic wears off to start controlling inflammation as soon as possible.
The experts CR consulted advise tailoring your treatment to your level of pain, adjusting your medications as the pain recedes.
For mild pain, an NSAID typically suffices says Moore. Your dentist may recommend taking a higher dose at first—600 mg of ibuprofen rather than the standard 200 mg to 400 mg—but never exceed the dosages stated on the label without your provider’s OK.
If you need further relief, you can add 325mg to 500mg of acetaminophen (one pill of regular- or extra-strength Tylenol.)
The new OTC pain reliever Advil Dual Action combines acetaminophen and ibuprofen, a convenient formulation that may work against milder pain. “The doses of ibuprofen and acetaminophen found in Advil Dual Action have been shown to provide safe and effective pain relief following minor dental surgery and simple tooth extractions,” Moore says.
But, Moore adds, the lower doses of pain relievers in this new product may be inadequate for some patients with more severe pain. “Higher doses of ibuprofen and acetaminophen may be appropriate for more complex and traumatic oral surgical procedures such as extraction of multiple impacted wisdom teeth.”
Don’t Get More Opioids Than Needed
For severe pain, which typically arises from more intensive procedures such as bone removal, taking an opioid can provide additional relief if OTC pain medications are not enough, Dionne says. In that case, your dentist should prescribe only enough to cover the first two or three days after your procedure. After that, you should be able to comfortably transition to other forms of pain relief.
Dentists most prescribe drugs such as Percocet, Tylenol with Codeine (Tylenol No.3), and Vicodin, all of which combine a low dose of an opioid with acetaminophen in one drug. Your dentist may recommend that you take an NSAID as well to treat inflammation. But never combine a prescription medication containing acetaminophen with an OTC product that also contains that drug, including pain relievers such as Tylenol and many cough and cold drugs. Doubling up on acetaminophen can damage the liver and can be fatal.
If You Still Wind Up With Leftovers
Don’t hang on to them, especially the opioids. Many pharmacies, hospitals, clinics, narcotics treatment programs, and long-term-care centers will take leftover opioids and other expired medication. For example, both Walgreens and CVS have installed self-service kiosks in many of their stores where you can safely dispose of medications.
To find an authorized medication take-back program near you, use the online search tool maintained by the Drug Enforcement Administration. Or call the DEA’s Registration Call Center at 800-882-9539.
In addition, many retail and mail-order pharmacies provide free kits that allow you to safely discard medications at home. One example is DisposeRx, a packet of powder that, when mixed with water in a medication vial, turns the drugs into a thick gel that’s safe to toss in the trash. You can also buy similar products online.
Read more about disposing of unused or expired medications.