Treating dental pain with opioids linked to higher risk of overdose in patients & families

Study also shows certain patients have an even greater risk of overdose if they fill opioid prescriptions, and strengthens argument against use of opioids for most dental pain

MICHIGAN MEDICINE - UNIVERSITY OF MICHIGAN

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When they go to the dentist to get a tooth pulled or another procedure, patients might not think that the prescription they receive to ease their pain could put them or their family at risk of an opioid overdose.

But a new study from the University of Michigan shows that overdose rates were two and a half times higher among patients who filled a prescription for an opioid medication after a dental procedure, compared with those who didn't fill such a prescription.

Overdose rates were also higher among the family members of such patients - possibly from misuse of the leftover pills.

The study is published in the American Journal of Preventive Medicine by a team from the U-M Medical School and School of Dentistry. It used data from 8.5 million dental procedures in teen and adult patients between 2011 and 2018 whose care was covered by Medicaid or private dental insurance. Nearly 27% of these patients filled a prescription for an opioid such as hydrocodone or oxycodone.

The researchers identified 2,700 overdoses that occurred in the 90 days after a tooth extraction or 119 other dental procedures. That works out to about three overdoses for every 10,000 dental procedures. The rate was 5.8 per 10,000 among those who filled an opioid prescription within three days of their procedure, compared with 2.2 per 10,000 among those who didn't.

The researchers note that other data have shown that in 2016 alone, dentists wrote 11.4 million prescriptions for opioids. The new study's findings suggest that 1,700 overdoses a year could be happening because of dental opioid prescriptions.

Risks among family members

The study also used data from 3.5 million privately insured dental procedure patients to examine overdoses within 90 days in the patients' family members. The rate of overdose was 1.7 per 10,000 procedures in family members of privately insured patients who filled opioid prescriptions, compared with 1 per 10,000 procedures among those who didn't.

In the study, 400 family members of patients were treated for opioid overdoses in the 90-day period after the dental patient's procedure. In all, 42% of these overdoses were in the child of the patient who had a procedure, and another 25% were in a spouse; the rest were in parents and siblings.

Kao-Ping Chua, M.D., Ph.D., led the analysis. "Our paper shows that when patients fill dental opioid prescriptions, the risk of opioid overdose increases both for themselves and their family members," he says. "This underscores the importance of avoiding dental opioid prescribing when non-opioids like ibuprofen and acetaminophen are effective options for pain control, as is the case for the majority of dental procedures. Our finding of increased overdose risk in family members also shows the importance of emphasizing safe storage and disposal when prescribing opioids to dental patients."

Chua is a pediatrician at Michigan Medicine, a health care researcher at the Susan B. Meister Child Health Evaluation Research Center, and a member of the U-M Institute for Healthcare Policy and Innovation.

"To me, this is one of the most powerful truths we've unlocked in our 'big data' research on dental opioid prescribing," says senior author Romesh Nalliah, D.D.S., M.H.C.M. "That when a dentist, like me, prescribes an opioid to a patient I am putting their entire family at risk of overdose. Dentists should consider, if the family concerned was yours, would you take that risk?" Nalliah is associate dean for patient services at U-M School of Dentistry and a member of IHPI, and has led other research on dental opioid use.

The authors are part of the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), which has developed guidelines for dentists and surgeons to reduce or eliminate the prescribing of opioids for many procedures and operations, while still providing effective pain relief. Michigan OPEN recommends that dentists avoid prescribing opioids for most dental procedures because non-opioids are just as effective for pain.

Groups at higher risk of overdose after receiving dental opioids

The study also identifies specific groups of dental patients who are at a higher risk of opioid overdose after receiving opioid prescriptions.

Those groups include patients with diagnosed mental health conditions and substance use disorders, and those with Medicaid health coverage.

This knowledge could help dentists and oral surgeons choose the pain treatment for their patients more carefully, and include a prescription for the overdose treatment naloxone if they prescribe opioids to someone with a higher risk of overdose.

Study shows 2% of asymptomatic pediatric dental patients test positive for COVID-19

UNIVERSITY OF ILLINOIS AT CHICAGO

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A study by a University of Illinois Chicago pediatric dentist has shown a novel way to track potential COVID-19 cases -- testing children who visit the dentist. The study also showed an over 2% positivity rate for the asymptomatic children tested.

Dr. Flavia Lamberghini, UIC clinical assistant professor in the department of pediatric dentistry, has co-authored the article, "Severe acute respiratory syndrome coronavirus 2 infection in asymptomatic pediatric dental patients," in the April 2021 issue of the Journal of the American Dental Association. Co-authors are Dr. Fernando Testai, UIC professor of neurology and rehabilitation, and Dr. Gabriela Trifan, UIC assistant professor of neurology and rehabilitation.

The study looked at pediatric patients who visited UIC dental clinics for emergency dental procedures from April 1 to Aug. 1, 2020. Children with COVID-19 are typically asymptomatic but have the potential to carry substantial viral loads and be a source of infection. The patients were screened over the phone prior to their scheduled visits and were asymptomatic when they arrived for their appointments. They were given a polymerase chain reaction, or PCR, test for SARS-CoV-2 infection at their visit, Lamberghini said.

"The kids tolerated the test just fine. We were trained by a pediatrician on how to conduct the test. We used the nasal swab. We told the kids, 'We are putting a butterfly in your nose,''' Lamberghini said.

The patients, between the ages of 2 to 18, with a median age of 6, were tested. Sociodemographic characteristics were abstracted, and positivity rates were calculated. With the sample size of 921 patients, the overall SARS-Co-V-2 positivity rate was 2.3%. Positivity rates were statistically higher for Latino patients (3.1%), and 63% of the children studied were Latino.

Lamberghini notes the study did not extend to include variables, and questions about social distancing and exposure to the virus were not asked. However, when a child tested positive for COVID-19, researchers followed up with the child's pediatrician and caregivers and encouraged them to follow recommended advice.

"For most of them, it was a surprise to learn their child tested positive. It was good for families to know because these kids can transmit the virus, especially in communities where extended families tend to live together," Lamberghini said.

It's also important information for the oral health care providers as well, she added.

"As dentists, we are more exposed to the COVID-19 disease because we work close to the mouth, and our tools generate aerosols that can infect the dentist and dental assistant -- whoever is around," Lamberghini said.

Prior to the study, children receiving dental procedures were not required to undergo PCR tests. The study concluded that PCR testing for COVID-19 of asymptomatic patients in pediatric dentistry adds value to the use of screening questionnaires for the identification of infected people who could be contagious.

The study, the first to look at the prevalence of COVID-19 in pediatric dentistry, also serves as a reference for pediatric dentists who closed during the pandemic and are considering reopening, Testai said.

"Despite these children being COVID-positive, we did not observe transmission to clinic staff, supporting the notion that personal protective equipment works," Testai said.

Simple oral hygiene could help reduce COVID-19 severity - study

COVID-19 could pass into people's lungs from saliva with the virus moving directly from mouth to bloodstream - particularly if individuals are suffering from gum disease, according to new research.

Evidence shows that blood vessels of the lungs, rather than airways, are affected initially in COVID-19 lung disease with high concentrations of the virus in saliva and periodontitis associated with increased risk of death.

The researchers propose that dental plaque accumulation and periodontal inflammation further intensify the likelihood of the SARS-CoV-2 virus reaching the lungs and causing more severe cases of the infection.

Experts say this discovery could make effective oral healthcare a potentially lifesaving action - recommending that the public take simple, but effective, daily steps to maintain oral hygiene and reduce factors contributing to gum disease, such as the build-up of plaque.

An international team of researchers from the UK, South Africa and the United States today published their findings in the Journal of Oral Medicine and Dental Research. They note emerging evidence that specific ingredients of some cheap and widely available mouthwash products are highly effective at inactivating the SARS-CoV-2 virus.

Simple oral hygiene measures, including use of these specific mouthwash products, could help lower the risk of transmission of the virus from the mouth to the lungs in those with COVID-19, and help prevent severe instances of the infection.

Initial observations of lung CT scans from patients suffering from COVID-19 lung disease by Dr Graham Lloyd-Jones, a radiologist, led to a collaboration between medical and dental researchers on the potential entry route into the bloodstream.

Co-author Iain Chapple, Professor of Periodontology at the University of Birmingham, commented: "This model may help us understand why some individuals develop COVID-19 lung disease and others do not. It could also change the way we manage the virus - exploring cheap or even free treatments targeted at the mouth and, ultimately, saving lives.

"Gum disease makes the gums leakier, allowing microorganisms to enter into the blood. Simple measures - such as careful toothbrushing and interdental brushing to reduce plaque build-up, along with specific mouthwashes, or even saltwater rinsing to reduce gingival inflammation - could help decrease the virus' concentration in saliva and help mitigate the development of lung disease and reduce the risk of deterioration to severe COVID-19."

The research team comprised of experts from Salisbury District Hospital, UK; the University of Birmingham, UK; and the Mouth-Body Research Institute, Los Angeles, California and Cape Town, South Africa.

Their new model is based on the mouth providing a breeding ground for the virus to thrive, with any breach in oral immune defences making it easier for the virus to enter the bloodstream. Moving from blood vessels in the gums, the virus would pass through neck and chest veins - reaching the heart before being pumped into pulmonary arteries and small vessels in the lung base and periphery.

"Studies are urgently required to further investigate this new model, but in the meantime daily oral hygiene and plaque control will not only improve oral health and wellbeing, but could also be lifesaving in the context of the pandemic," added Professor Chapple.

Good dental health may help prevent heart infection from mouth bacteria

 

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Maintenance of good oral health is more important than use of antibiotics in dental procedures for some heart patients to prevent a heart infection caused by bacteria around the teeth, according to a new American Heart Association (AHA) scientific statement published today in the association's flagship journal, Circulation.

Infective endocarditis (IE), also called bacterial endocarditis, is a heart infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel. It is uncommon, but people with heart valve disease or previous valve surgery, congenital heart disease or recurrent infective endocarditis have a greater risk of complications if they develop IE. Intravenous drug use also increases risk for IE. Viridans group streptococcal infective endocarditis (VGS IE) is caused by bacteria that collect in plaque on the tooth surface and cause inflammation and swelling of the gums. There's been concern that certain dental procedures may increase the risk of developing VGS IE in vulnerable patients.

The new guidance affirms previous recommendations that only four categories of heart patients should be prescribed antibiotics prior to certain dental procedures to prevent VGS IE due to their higher risk for complications from the infection:

those with prosthetic heart valves or prosthetic material used for valve repair;

those who have had a previous case of infective endocarditis;

adults and children with congenital heart disease; or

people who have undergone a heart transplant.

"Scientific data since the 2007 AHA guidelines support the view that limited use of preventive antibiotics for dental procedures hasn't increased cases of endocarditis and is an important step at combating antibiotic overuse in the population," said Walter R. Wilson, M.D., chair of the statement writing group and a consultant for the Division of Infectious Diseases, Department of Internal Medicine at Mayo Clinic in Rochester, Minn.

It has been over a decade since recommendations for preventing infective endocarditis were updated amid concerns of antibiotic resistance due to overprescribing. The American Heart Association's 2007 guidelines, which presented the biggest shift in recommendations from the Association on the prevention of infective endocarditis in more than 50 years, more tightly defined which patients should receive preventive antibiotics before certain dental procedures to the four high-risk categories. This change resulted in about 90% fewer patients requiring antibiotics.

The scientific statement writing group reviewed data on VGS IE since the 2007 guidelines to determine if the guidelines had been accepted and followed, whether cases of and mortality due to VGS IE have increased or decreased, and if the guidance might need to be adjusted.

The writing committee reports their extensive review of related research found:

There was good general awareness of the changes in the 2007 guidelines, however, adherence to the guidelines was variable. There was about a 20% overall reduction in prescribing preventive antibiotics among high-risk patients, a 64% decrease among moderate-risk patients, and a 52% decrease in those patients at low- or unknown-risk.

In a survey of 5,500 dentists in the U.S., 70% reported prescribing preventive antibiotics to patients even though the guidelines no longer recommend it, and this was most often for patients with mitral valve prolapse and five other cardiac conditions. The dentists reported that about 60% of the time the antibiotic regimen was recommended by the patient's physician, and 1/3 of the time was according to patient preference.

Since the stricter 2007 antibiotic guidelines, there is no convincing evidence of an increase in cases of VGS IE or increased mortality due to VGS IE.

The writing group supports the 2007 recommendation that only the highest risk groups of patients receive antibiotics prior to certain dental procedures to help prevent VGS IE.

In the presence of poor oral hygiene and gingival disease, VGS IE is far more likely to develop from bacteria attributable to routine daily activities such as toothbrushing than from a dental procedure.

Maintenance of good oral hygiene and regular access to dental care are considered as important in preventing VGS IE as taking antibiotics before certain dental procedures.

It is important to connect patients with services to facilitate access to dental care and assistance with insurance for dental coverage, especially in those patients at high risk for VGS IE.

It is still appropriate to follow the recommendation to use preventive antibiotics with high-risk patients undergoing dental procedures that involve manipulation of the gum tissue or infected areas of the teeth, or perforation of the membrane lining the mouth.

The scientific statement was prepared by the volunteer writing committee on behalf of the American Heart Association's Young Hearts Rheumatic Fever, Endocarditis and Kawasaki Disease Committee; the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Cardiovascular and Stroke Nursing; and the Council on Quality of Care and Outcomes Research.

Bacteria that cause periodontitis are transmitted from parents to children

A study led by researchers at the University of Campinas reinforces the need for prevention and follow-up treatment starting in early childhood to avoid development of this inflammatory disease of the gums.

FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULO

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IMAGE: A STUDY REINFORCES THE NEED FOR PREVENTION AND FOLLOW-UP TREATMENT STARTING IN EARLY CHILDHOOD TO AVOID DEVELOPMENT OF THIS INFLAMMATORY DISEASE OF THE GUMS view more 

CREDIT: MABELLE DE FREITAS MONTEIRO

By Luciana Constantino | Agência FAPESP– Adults with periodontitis transmit bacteria that can cause the disease in future to their children, and the bacteria remain in the oral cavity even when the children undergo treatment of various kinds, reinforcing the need for preventive care in the first year of a baby’s life. This is the main conclusion of a study conducted at the University of Campinas (UNICAMP) in the state of São Paulo, Brazil. An article on the study is published in Scientific Reports.

Periodontitis is an inflammation of the periodontium, the tissue that supports the teeth and maintains them in the maxillary and mandibular bones. The disease is triggered by bacterial infection. Symptoms include bleeding of the gums and halitosis. In severe cases, it leads to bone and tooth loss. If the bacteria or other microorganisms that cause the disease enter the bloodstream, they may trigger other kinds of inflammation in the body. Treatment includes cleaning of the pockets around teeth by a dentist or hygienist and administration of anti-inflammatory drugs or antibiotics.

“The parents’ oral microbiome is a determinant of the subgingival microbial colonization of their children,” the article’s authors state in their conclusions, adding that “dysbiotic microbiota acquired by children of periodontitis patients at an early age are resilient to shift and the community structure is maintained even after controlling the hygiene status”.

According to dental surgeon Mabelle de Freitas Monteiro, first author of the article, she and her group have been researching periodontitis for ten years, observing parents with the disease and its impact on their children’s health.

“If the findings are applied to day-to-day dental practice, the study can be said to help design more direct approaches. Knowing that periodontal disease may affect the patient’s family is an incentive to use preventive treatment, seek early diagnosis and mitigate complications,” said Monteiro, who was supported by FAPESP via two projects (16/03704-7 and 16/19970-8).

The principal investigator for both projects was Renato Corrêa Viana Casarin, a professor at UNICAMP’s Piracicaba Dental School (FOP) and last author of the article.

For Casarin, parents should start caring for the health of their children’s gums when they are infants. “This pioneering study compares parents with and without periodontitis. In children of the former, we found subgingival bacterial colonization at a very early age. However, ‘inheriting’ the problem doesn’t mean a child is fated to develop the disease in adulthood. Hence the importance of keeping an eye open for the smallest signs and seeking specialized help,” Casarin said.

Data on the Brazilian population’s oral health is scarce. According to the last national dental epidemiological survey, conducted by the Ministry of Health in 2010, 18% of children aged 12 had never been to the dentist and 11.7% had experienced bleeding of the gums. In the 15-19 age group, 13.6% had never visited a dental clinic. Another survey was scheduled for 2020 but had to be postponed because of the COVID-19 pandemic.

The São Paulo State Department of Health published the findings of its latest oral health survey in 2019, showing among other things that 50.5% of adults aged 35-44 complained of toothache, bleeding gums and periodontitis (read more at: agencia.fapesp.br/30260/).

Bacteria

In the FOP-UNICAMP study led by Casarin and Monteiro, samples of subgingival biofilm and plaque were collected from 18 adults with a history of generalized aggressive (grade C) periodontitis, their children aged 6-12, and 18 orally healthy adults.

In addition to a clinical analysis, the samples were also subjected to a microbiological analysis and genetic sequencing by researchers at Ohio State University in the United States under the supervision of Professor Purnima Kumar.

“Children of periodontitis parents were preferentially colonized by Filifactor alocis, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Streptococcus parasanguinis, Fusobacterium nucleatum and several species belonging to the genus Selenomonas even in the absence of periodontitis,” the article states. “These pathogens also emerged as robust discriminators of the microbial signatures of children of parents with periodontitis.”

Casarin told Agência FAPESP that despite bacterial plaque control and vigorous brushing the children of people with the disease still had the bacteria in their mouths, whereas the effects of dental hygiene and prophylaxis were more significant in the children of healthy subjects.

“Because the parents had periodontitis, their children assumed this community with disease characteristics. They carried the bacterial information into their adult lives,” he said, adding that the analysis of bacterial colonization pointed to a greater likelihood of transmission by the mother. The research group will now work with pregnant women in an effort to “break the cycle” by preventing bacterial colonization of their children’s mouths.

“We’ll treat the mothers during pregnancy, before the babies are born, and try to find out if it’s possible to prevent bacterial colonization from occurring,” Casarin said, noting that studies with patients will proceed only when control of the pandemic permits.

Recognition

The periodontitis research group led by Casarin has won prizes at home and abroad. In 2019, Monteiro topped the clinical research category of the IADR’s Hatton Competition. The IADR (International Association for Dental Research) hosts the world’s leading conference on dentistry, and the competition is designed to provide an opportunity for the best junior investigators to present their research (read more in Portuguese at: www.fop.unicamp.br/index.php/pt-br/doi-odontopediatria/2352.html).

Years earlier the group won an award from the American Academy of Periodontology for the study with the most significant clinical impact.

The article “Parents with periodontitis impact the subgingival colonization of their offspring” is at: www.nature.com/articles/s41598-020-80372-4.