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New largescale study in the American Journal of Preventive Medicine found overprescription of opioids by dentists common, particularly to patients at high risk for substance abuse, and that almost 1/3 of patients received more powerful drugs than needed
Ann Arbor, February 4, 2020 – Dentists are among top prescribers of opioids in the US, however, whether their opioid prescribing exceeds guidance had not been investigated. A new study in the American Journal of Preventive Medicine, published by Elsevier, indicates that more than half of opioid prescriptions issued by dentists exceed the three-day supply recommended by the US Centers for Disease Control and Prevention (CDC) for acute dental pain management. The findings also show that 29 percent of dental patients received more powerful opioids than needed for expected post-procedure pain.
"Unlike national trends, opioid overprescribing by dentists is increasing. Our results should initiate a call to action to professional organizations and public health and advocacy groups to improve the guidelines for prescribing opioids for oral pain. As high prescribers of opioids writing prescriptions for a tenth of the opioids dispensed in the US, dentists should be included as part of the multi-faceted solution needed for the opioid epidemic," explained lead investigator Katie J. Suda, PharmD, MS, Professor, University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA, USA.
The study used Truven Health MarketScan Research Databases to assess close to 550,000 dental visits by adult patients between 2011 and 2015, prior to the implementation of the 2016 CDC guidelines for pain management. These guidelines recommend first-line treatment using non-opioid analgesics for oral pain when possible. If stronger analgesics are needed after dental surgery, low-potency opioids (e.g., acetaminophen with codeine) are recommended instead of high-potency opioids (e.g., oxycodone). Moreover, three days or less of treatment is considered sufficient for typical oral pain. It is also a best practice for dentists to check their local prescription drug monitoring program (PDMP) before they write a prescription for any opioid to identify patients at risk of opioid abuse.
Investigators also found that the proportion of prescribed opioids that exceeded the recommended morphine equivalents increased in 2015. This was likely due to an increase in the quantity of hydrocodone tablets dispensed after the Food and Drug Administration’s (FDA) rescheduling of hydrocodone from a schedule III to a schedule II drug in 2014. While hydrocodone rescheduling was associated with a decrease in hydrocodone prescribing nationally, this study’s results suggest that this change resulted in an average increase of two tablets dispensed per hydrocodone prescription prescribed by dentists. Nationally, this increase translates to more than14 million additional hydrocodone tablets dispensed to patients after rescheduling hydrocodone to a schedule II drug.
"Similar to medical providers, dentists need to be provided resources to aid in their prescribing decisions for pain medications," commented Dr. Suda. "This should include clinical guidelines specific to oral pain and education on how to talk to their patients about treating their oral pain."
Co-investigator Susan A. Rowan, DDS, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA, emphasized that the demographic groups most impacted by overprescribing (patients aged 18 to 34 years, men, those living in the Southern US, and those receiving oxycodone) also carry a higher risk of addiction and overdose. She suggested that "additional studies are needed to evaluate the efficacy of the CDC 2016 prescribing guidelines subsequent to their introduction."
"Future studies and targeted efforts to reduce overprescribing would also be well motivated among older patients and others taking multiple other high risk medications such as benzodiazepines," added Gregory S. Calip, PharmD, MPH, PhD, College of, Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
Dr. Suda and co-investigators invite professional organizations and public health and advocacy groups to use the study’s data to inform future efforts. In the interim, they recommend that individual dentists implement their own practice-specific guidelines, favoring ibuprofen plus acetaminophen and low-potency opioids for post-extraction pain management.
Using statistical modeling, investigators predict that overprescribing would decrease by more than 20 percent if oxycodone prescriptions were substituted with lower potency opioids (such as hydrocodone).
As he received his goody bag with dental hygiene products, he wondered why not conduct a study and have primary care providers do the same thing for their patients who use tobacco. The bags would contain educational material, free lozenges and tobacco cessation medications to encourage people to stop smoking.
Results from the study, recently published online in Addiction, weren’t surprising to Carpenter. He and colleagues found providing smokers with a free, two?week starter kit of nicotine replacement therapy (NRT) increased quit attempts, use of stop smoking medications, and smoking abstinence as compared with standard care in a primary care setting.
"Not a day went by in this study when I was not excited by it because I knew that we were having an impact on real patients in the real world with their doctors," Carpenter said. "This gets the patients to know that their doctor cares, and they have something they can use right now."
Carpenter believes a smoker’s annual visit to the doctor creates the perfect window of opportunity for a physician to provide a quick intervention, while providing tools to help smokers begin the process of quitting. Along with advice on why and how a patient should stop smoking, a person should be able to walk away with a product they can use immediately to try and stop their dependence on nicotine.
"About 70 percent of smokers will see their primary care providers on a yearly basis," Carpenter said. "It’s a clinical encounter to do something, but I think we can offer them tools other than words."
In the U.S., 34 million adults currently smoke cigarettes and nearly 70 percent of U.S. adults who smoke say they want to quit, according to the 2020 Surgeon General’s Report.
The $2 million study, Tobacco Intervention in Primary Care: Treatment Opportunities for Providers, also known as Tip Top, included 22 clinics throughout South Carolina and was conducted in collaboration with the National Institute of Drug Abuse (NIDA). A total of 1,245 patients participated in the study.
The study included 652 patients from 12 of the clinics who only received advice on the importance of quitting smoking. The remaining 593 patients at 10 clinics were provided with samples of medication to use including nicotine patches and lozenges. During the study, all smokers were advised to quit through a regular conversation with their physician.
They also received information and resources to help them quit smoking and information about Quitline, a tobacco cessation service available through a toll-free telephone number.
Carpenter said that the study was well-received by primary care providers, who welcomed the goody bag as a conversation starter. "The doctors are giving something that is concrete and immediately actionable," Carpenter said. "The patient can go home and use the products that day."
During this study, 26 percent of patients who received the NRT samples achieved at least one week without smoking. "If you can achieve seven days in a row of not smoking, I’m going to call that success," Carpenter said.
The study also found that 12 percent of patients were quit at final follow-up (six months). While this may seem a modest amount, it’s more than 150 patients who potentially will save thousands in medical costs if they are able to quit smoking, all for just the cost of a $70 intervention. "That has to be cost-effective no matter you slice it," says Carpenter.
On average, it takes a patient seven to 10 attempts of trying to quit smoking before becoming successful, so interventions such as this can be helpful in the process. Even for the smokers who didn’t use the products, it planted a seed, he said.
An interesting finding during this study showed that the smoking cessation bags with information and medication were more beneficial to patients who had a lower income, lower education or if they were in the more rural areas of the state. The finding on income, education, and rurality is an area Carpenter would like to study more in the future.
"It’s about access," Carpenter said. "We’re helping people who are struggling out there to find and succeed in treatment."
Given the toll of smoking-related health conditions, Carpenter said he hopes insurance companies will see the value and provide funding in the future so that primary care physicians could offer this to their patients. The concept also could be used for smokers who are leaving the hospital, or even those who have been incarcerated.
"These samples can be given out almost universally – even to smokers who may not want to quit and who may not yet be ready to try medications," Carpenter said. "It’s a pragmatic and brief intervention that takes minutes to deliver and is scalable as an intervention to be used a variety of settings."
Smoking cessation reduces the risk of twelve cancers, including cancers of the lung; larynx; oral cavity and pharynx; esophagus; pancreas; bladder; stomach; colon and rectum; liver; cervix; kidney; and acute myeloid leukemia.
Carpenter said the intervention provides patients a starting point to their journey of becoming smoke-free and it’s simple to use for primary care providers, who don’t feel pressured to have a long lecture. They can just offer their patients support.
"This is about cancer prevention. Smoking cessation is cancer prevention," Carpenter said.
Children with higher concentrations of a certain chemical in their blood are more likely to get cavities, according to a new study by West Virginia University School of Dentistry researchers.
Manufactured chemical g roups called perfluoroalkyl and polyfluoroalkyl substances are universal as a result of extensive manufacturing and use. Although manufacturers no longer use PFAS to make nonstick cookware, carpet, cardboard and other products, they persist in the environment. Scientists have linked them to a range of health problems–from heart disease to high cholesterol–but now R. Constance Wiener and Christopher Waters are exploring how they affect dental health.
They investigated whether higher concentrations of PFAS were associated with greater tooth decay in children. One of them–perfluorodecanoic acid–was linked to dental cavities. Their findings appear in the Journal of Public Health Dentistry.
"Due to the strong chemical bonds of PFAS, it is difficult for them to breakdown, which makes them more likely to be persistent within the environment, especially in drinking water systems," said Waters, who directs the School of Dentistry’s research labs. "A majority of people may not be aware that they are using water and other products that contain PFAS."
The 629 children who participated in the study were 3 to 11 years old and were part of the National Health and Nutrition Examination Survey. Samples of the children’s blood were analyzed for PFAS in 2013 and 2014. Their tooth decay and other factors–such as their race, their BMI and how often they brushed their teeth–were assessed.
Of the seven PFAS that Wiener and Waters analyzed, perfluorodecanoic acid was the one that correlated with higher levels of tooth decay.
"Perfluorodecanoic acid, in particular, has a long molecular structure and strong chemical bonds; therefore, it remains in the environment longer. As a result, it is more likely to have negative health consequences such as dental caries," said Dr. Wiener, an associate professor in the Department of Dental Practice and Rural Health.
But how does that influence happen? Wiener and Waters have a hypothesis. According to other research, perfluorodecanoic acid may disrupt the healthy development of enamel, which is what makes teeth hard. That disruption can leave teeth susceptible to decay.
However, when it comes to cavities, scientists haven’t parsed perfluorodecanoic acid’s mechanism of action yet. The topic warrants further investigation.
"While the findings of this study are important, there are some study limitations, and more work is needed to fully understand how this molecule impacts normal tooth formation," said Fotinos Panagakos, the School of Dentistry’s vice dean for administration and research.
"The good news is that, in our study, about half of the children did not have any measurable amount of PFAS. Perhaps this is due to certain PFAS no longer being made in the US," Wiener said.
Another piece of good news is that the study reaffirmed the importance of dental hygiene and checkups. Children who brushed once a day or less frequently had significantly higher tooth decay than those who brushed at least twice daily.
Likewise, children who had not been to the dentist within the previous year were twice as likely to have higher rates of tooth decay than kids who hadn’t.
So, even though parents cannot control what is in their children’s drinking water, they can still protect their children’s teeth by fostering thorough, regular brushing and scheduling dental exams.
The School of Dentistry will hold Give Kids a Smile Day on Friday, Feb. 7, at the Pediatric Dentistry Clinic. Dental students will treat more than 100 children for free that day. Each visit includes an exam, a cleaning, a fluoride treatment and–if appropriate–X-rays.
Title: Perfluoroalkyls/polyfluoroalkyl substances and dental caries experience in children, ages 3-11 years, National Health and Nutrition Examination Survey, 2013-2014
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American Chemical Society
Cavities, or dental caries, are the most widespread non-communicable disease globally, according to the World Health Organization. Having a cavity drilled and filled at the dentist’s office can be painful, but untreated caries could lead to worse pain, tooth loss, infection, and even illness or death. Now, researchers in ACS Applied Materials & Interfaces report a bioactive peptide that coats tooth surfaces, helping prevent new cavities and heal existing ones in lab experiments.
Conventional treatment for dental cavities involves removing decayed tissue and filling the hole with materials, such as amalgam or composite resin. However, this procedure can damage healthy tissue and cause severe discomfort for patients. Hai Ming Wong, Quan Li Li and colleagues wanted to develop a two-pronged strategy to prevent and treat tooth decay: 1) prevent colonization of the tooth surface by the plaque-forming bacteria that cause cavities, and 2) reduce demineralization, or the dissolving of tooth enamel, while increasing remineralization, or repair.
The researchers based their anti-cavity coating on a natural antimicrobial peptide called H5. Produced by human salivary glands, H5 can adsorb onto tooth enamel and destroy a broad range of bacteria and fungi. To promote remineralization, the team added a phosphoserine group to one end of H5, which they thought could help attract more calcium ions to repair the enamel than natural H5. They tested the modified peptide on slices of human molars. Compared with natural H5, the new peptide adsorbed more strongly to the tooth surface, killed more bacteria and inhibited their adhesion, and protected teeth from demineralization. Surprisingly, however, both peptides promoted remineralization to a similar degree. After brushing, people could someday apply the modified peptide to their teeth as a varnish or gel to protect against tooth decay, the researchers say.