Non-opioid pain relievers beat opioids after dental surgery

A combination of acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) controls pain after wisdom tooth removal better than opioids, according to a Rutgers Health study that could change how dentists treat post-surgical pain.

The trial in more than 1,800 patients found that those given a combination of ibuprofen and acetaminophen experienced less pain, better sleep and higher satisfaction compared with those receiving the opioid hydrocodone with acetaminophen.

“We think this is a landmark study,” said Cecile Feldman, dean of Rutgers School of Dental Medicine and lead author of the study. “The results actually came in even stronger than we thought they would.”

Dentists, who rank among the nation’s leading prescribers of opioids, wrote more than 8.9 million opioid prescriptions in 2022. For many young adults, dental procedures such as wisdom tooth extraction are their first exposure to opioid medications.

“There are studies out there to show that when young people get introduced to opioids, there's an increased likelihood that they're going to eventually use them again, and then it can lead to addiction,” said study co-investigator Janine Fredericks-Younger, adding that opioid overdoses kill more than 80,000 Americans each year.

To compare opioid and non-opioid pain relief, the researchers conducted a randomized trial on patients undergoing surgical removal of impacted wisdom teeth, a common procedure that typically causes moderate to severe pain.

Half the patients received hydrocodone with acetaminophen. The other half got a combination of acetaminophen and ibuprofen. Patients rated their pain levels and other outcomes, such as sleep quality, over the week following surgery.

Results in The Journal of American Dental Association showed the non-opioid combination provided superior pain relief during the peak-pain period in the two days after surgery. Patients taking the non-opioid medications also reported better sleep quality on the first night and less interference with daily activities throughout recovery.

Patients who received the over-the-counter combo were only half as likely as the opioid patients to require additional "rescue" pain medication. They also reported higher overall satisfaction with their pain treatment.

“We feel pretty confident in saying that opioids should not be prescribed routinely and that if dentists prescribe the non-opioid combination, their patients are going to be a lot better off,” Feldman said.

The study's size and design make it particularly notable. With more than 1,800 participants across five clinical sites, it's one of the largest studies of its kind. It also aimed to reflect real-world medication use rather than the tightly controlled conditions of many smaller pain studies.

“We were looking at the effectiveness – so how does it work in real life, taking into account what people really care about,” said Feldman, referring to the study’s focus on sleep quality and the ability to return to work.

The findings align with recent recommendations from the American Dental Association to avoid opioids as first-line pain treatment. Feldman said she hopes they will change prescribing practices.

“For a while, we've been talking about not needing to prescribe opioids,” Feldman said. “This study’s results are such that there is no reason to be prescribing opioids unless you've got those special situations, like medical conditions preventing the use of ibuprofen or acetaminophen.”

Members of the research team said they hope to expand their work to other dental procedures and pain scenarios. Other researchers at the school are testing cannabinoids for managing dental pain.

“These studies not only guide us on how to improve current dental care,” said Feldman, “but also on how we can better train future dentists here at Rutgers, where we constantly refine our curriculum the light of science."

Investigation uncovers poor quality of dental coverage under Medicare Advantage

 

Mass General Brigham researchers found that only 8.4% of Medicare Advantage plans offered a dental benefit that met quality standards

Peer-Reviewed Publication

Mass General Brigham

Medicare Advantage—the privatized form of Medicare that offers benefits beyond traditional Medicare, such as dental insurance—is gaining in popularity, but a new analysis reveals that the quality of dental coverage offered by Medicare Advantage is poor, with only 8.4 percent of plans offering a dental benefit that met the study’s quality standards. The research led by a team from Mass General Brigham is published in JAMA.

 

“Our study suggests that many Medicare Advantage beneficiaries may not have access to the dental care they need, even if they are enrolled in a plan that nominally provides them with dental coverage,” said first author Lisa Simon, MD, DMD, of the Division of General and Internal Medicine at Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system.

 

Simon and her colleagues examined Medicare data from late 2023, and they developed a list of requirements for a comprehensive dental benefit that would be on par with employer-sponsored plans (such as offering dental cleanings without a co-pay, having an annual maximum coverage of at least $1,500, and not requiring an additional premium to have access to these dental services).

The team’s analysis included 6,333 Medicare advantage plans with a total enrollment of more than 27 million beneficiaries. The investigators found that 86.6% of plans offered a dental benefit, but only 8.4% offered a comprehensive benefit that met quality standards. Also, 94% of Medicare beneficiaries were enrolled in a plan that offered a dental benefit, but only 4.1% were enrolled in a plan with a comprehensive dental benefit.

 

These research findings might explain why only about half of Medicare Advantage beneficiaries visit the dentist annually, which is similar to the rate for beneficiaries in traditional Medicare that lacks most dental coverage.

 

“Many of the attributes we studied—like how much coinsurance a patient would need to pay or whether procedures like fillings or crowns are covered—are fairly complex and probably pretty overwhelming for consumers to review during open enrollment season,” said Simon. “Regulations could prevent low-quality dental plans from being offered in the first place and ensure that consumers actually know what they’re getting when they pick a Medicare Advantage plan.” 

 

Authorship: Additional authors include Marko Vujicic and Kamyar Nasseh.

Disclosures: Simon reported receiving grants from CareQuest Institute for Oral Health and National Institute of Dental and Craniofacial Research; and personal fees from American Dental Association, American Dental Therapy Association, California Dental Association, Santa Fe Group, and American College of Dentists outside the submitted work.

Funding: Simon reported funding from the Brigham and Women’s Hospital Faculty Career Development Award.

Paper cited: Simon L et al. “Availability of Dental Benefits Within Medicare Advantage Plans by Enrollment and County” JAMA DOI: 10.1001/jama.2024.24814

Researchers are learning what happens to our teeth as we age

 

Peer-Reviewed Publication

University of Washington

 

image: 

A research team at the University of Washington and the Pacific Northwest National Laboratory examined the atomic composition of enamel samples from two human teeth. The researchers found that samples from an older person contained higher levels of the ion fluoride. Shown here, Jack Grimm, UW doctoral student in materials science and engineering and a doctoral intern at PNNL, prepares an enamel sample for atom probe tomography by loading it into a plasma-focused, ion-beam scanning electron microscope.

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Credit: Andrea Starr/Pacific Northwest National Laboratory

Teeth are essential for helping people break down the food they eat, and are protected by enamel, which helps them withstand the large amount of stress they experience as people chew away. Unlike other materials in the body, enamel has no way to repair damage, which means that as we age, it risks becoming weaker with time.

Researchers are interested in understanding how enamel changes with age so that they can start to develop methods that can keep teeth happier and healthier for longer.

A research team at the University of Washington and the Pacific Northwest National Laboratory examined the atomic composition of enamel samples from two human teeth — one from a 22-year-old and one from a 56-year-old. The sample from the older person contained higher levels of the ion fluoride, which is often found in drinking water and toothpaste, where it’s added as a way to help protect enamel (though its addition to drinking water has recently been a topic in the news).

The team published these findings Dec. 19 in Communications Materials. While this is a proof-of-concept study, these results have implications for how fluoride is taken up and integrated into enamel as people age, the researchers said.

"We know that teeth get more brittle as people age, especially near the very outer surface, which is where cracks start," said lead author Jack Grimm, UW doctoral student in materials science and engineering and a doctoral intern at PNNL. "There are a number of factors behind this — one of which is the composition of the mineral content. We're interested in understanding exactly how the mineral content is changing. And if you want to see that, you have to look at the scale of atoms."

Enamel is composed mostly of minerals that are arranged in repetitive structures that are ten thousand times smaller than the width of a human hair.

"In the past, everything that we've done in my lab is on a much larger scale — maybe a tenth the size of a human hair," said co-senior author Dwayne Arola, UW professor of materials science and engineering. "On that scale, it's impossible to see the distribution of the relative mineral and organic portions of the enamel crystalline structure."

To examine the atomic composition of these structures, Grimm worked with Arun Devaraj, a materials scientist at PNNL, to use a technique called "atom probe tomography," which allows researchers to get a 3D map of each atom in space in a sample.

The team made three samples from each of the two teeth in the study and then compared differences in element composition in three different areas of the tiny, repetitive structures: the core of a structure, a "shell" coating the core, and the space between the shells.

In the samples from the older tooth, fluoride levels were higher across most of the regions. But they were especially high in the shell regions.

"We are getting exposed to fluoride through our toothpaste and drinking water and no one has been able to track that in an actual tooth at this scale. Is that fluoride actually being incorporated over time? Now we're starting to be able to paint that picture," said co-author Cameron Renteria, a postdoctoral researcher in both the oral health sciences and the materials science and engineering departments at the UW. "Of course, the ideal sample would be a tooth from someone who had documented every time they drank fluoridated versus non-fluoridated water, as well as how much acidic food and drink they consumed, but that's not really feasible. So this is a starting point."

The key to this research, the team said, is the interdisciplinary nature of the work.

"I am a metallurgist by training and didn't start to study biomaterials until 2015 when I met Dwayne. We started to talk about the potential synergy between our areas of expertise — how we can look at these small scales to start to understand how biomaterials behave," Devaraj said. "And then in 2019 Jack joined the group as a doctoral student and helped us look at this problem in depth. Interdisciplinary science can facilitate innovation, and hopefully we'll continue to address really interesting questions surrounding what happens to teeth as we age."

One thing the researchers are interested in studying is how protein composition of enamel changes over time.

"We set out trying to identify the distribution of the organic content in enamel, and whether the tiny amount of protein present in enamel actually goes away as we age. But when we looked at these results, one of the things that was most obvious was actually this distribution of fluoride around the crystalline structure," Arola said. "I don't think we have a public service announcement yet about how aging affects teeth in general. The jury is still out on that. The message from dentistry is pretty strong: You should try to utilize fluoride or fluoridated products to be able to fight the potential for tooth decay."

Semanti Mukhopadhyay, a postdoctoral researcher at PNNL, is also a co-author on this paper. This research was funded by the National Institutes of Health, Colgate-Palmolive Company and a distinguished graduate research program between PNNL and UW.

Early childhood exposure to fluoride does not have effects on cognitive neurodevelopment.

  The International Association for Dental, Oral, and Craniofacial Research (IADR) and the American Association for Dental, Oral, and Craniofacial Research (AADOCR) have announced the publication of a new study in Journal of Dental Research that examines how cognitive development among young children is affected by early exposure to fluoride.

It is important to maintain confidence in the risk and benefit balance of major caries-preventive programs using fluoride. The ongoing debate about potential effects of early life exposures to fluoride on cognitive neurodevelopment requires high quality scientific evidence. The new study by Loc Do, The University of Queensland Faculty of Health and Behavioural Sciences, School of Dentistry, Brisbane, Australia, et al. aimed to investigate potential effects of fluoride exposure on cognitive neurodevelopment assessed with the Wechsler Adult Intelligence Scale 4th edition (WAIS-IV) in an Australian population-based sample.

“The fluoridation of drinking water has been enormously beneficial to oral health over the decades, and to public health more generally,” said AADOCR President Effie Ioannidou. “It is crucial that a wealth of scientific evidence always be available should the public ever need reminding of this fact.”

The sample was selected from the National Child Oral Health Study (NCOHS) 2012-14. NCOHS collected data on socioeconomic factors, oral health behaviors, and residential history to estimate percent lifetime exposure to fluoridated water during the first five years of life (%LEFW). NCOHS children were also examined by trained and calibrated examiners to assess dental fluorosis (a reliable and valid individual biomarker of total fluoride intake during early childhood). The sample was followed up in 2022-23 to collect data on cognitive neurodevelopment (intelligence quotient (IQ)) using the WAIS-IV, which was administered by trained and calibrated qualified psychologists.

Multivariable regression models were generated to investigate associations between the two exposure measurements (%LEFW and dental fluorosis) with full-scale IQ (FSIQ) scores, controlling for important confounding effects. Hypotheses of noninferiority were also tested contrasting different levels of exposure to fluoride. Some 357 participants aged 16-26 years completed WAIS-IV, with a mean FSIQ score of 109.2 (95%CI: 107.8-110.5). The multivariable regression models’ estimates demonstrated slightly higher the FSIQ scores among the exposed than the non-exposed. Adjusted β of 100%LEFW vs. 0%LEFW was 1.07 (95%CI: -2.86, 5.01), and of having dental fluorosis vs. no fluorosis was 0.28 (95%CI: -3.00, 3.57).

The hypothesis of non-inferiority tests found that the FSIQ scores of those exposed and non-exposed to fluoride were equivalent. The study provided consistent evidence that early childhood exposure to fluoride does not have effects on cognitive neurodevelopment.

Chewing xylitol gum linked to decrease in preterm birth

 

Study participants in the group which chewed gum with xylitol twice a day saw a 24% drop in preterm births and a 30% drop in low-birthweight babies, 

Peer-Reviewed Publication

University of Washington School of Medicine/UW Medicine

Could the incidence of preterm births be lowered by … chewing gum?

New research suggests “yes.”

Results from a study in Malawi showed that chewing gum containing xylitol, a naturally occurring alcohol sugar, was associated with a 24% reduction in preterm birth. The findings were published today in Med (a Cell Press journal).

Researchers found that the group of pregnant individuals randomized to receive chewing gum also saw a 30% drop in low-birthweight babies, when compared with the control group which did not receive xylitol gum, noted lead author Dr. Greg Valentine, associate professor of pediatrics at the University of Washington School of Medicine. 

“It surprised us all that such a simple intervention could have such a dramatic effect,” said Valentine. 

The study followed two randomly selected groups of patients over three years in Malawi with over 10,000 participants, noted senior author Dr. Kjersti Aagaard, medical director of HCA Healthcare, who started the study at Baylor College of Medicine. 

A total of 4,549 patient participants received the xylitol chewing gum intervention while 5,520 the control group received traditional counseling and medication. The study was conducted from May 2015 to October 2018. The data analysis and follow-up was completed in October 2021.

Previous research has shown that, during pregnancy, periodontal disease (also known as gum disease) is associated with a two- to threefold increase in risk for preterm birth and low-birthweight delivery. 

While little evidence exists to identify the mechanism behind this link, it might be explained by the inflammatory response associated with periodontal disease, or through the spread of bacteria from the mouth through the bloodstream to organs throughout the body, the researchers surmised. 

In humans, 1 mm of dental plaque contains 100 million bacteria, including pathogens. These bacteria can cause infection and inflammation throughout the body, the report stated. 

Xylitol is a naturally occurring sugar alcohol sweetener used in chewing gum, lozenges and candies that have probiotic properties. Studies have shown that xylitol can both reduce the growth of bacteria strongly associated with periodontal disease and independently reduce inflammation in gum tissues, researchers noted.  

In the Prevention of Prematurity and Xylitol trial, participants were enrolled before they became pregnant and in early pregnancy (before 20 weeks gestation) and followed until birth. Trying to treat periodontal disease via traditional methods, such as deep cleaning to remove plaque under the gum tissue, and encouraging the use of toothbrushes and toothpaste, is difficult in low-resource countries due to lack of supplies, shortages of healthcare workers, and the lack of clean running water, Valentine said. 

A simple intervention like chewing gum helps overcome those issues by improving oral health in a more accessible manner, he said.

The individuals enrolled in the trial in eight Malawi health centers chewed xylitol-containing gum from early pregnancy until delivery.

“Basically, we know that periodontal disease is associated with preterm birth,” Valentine said.  “This is particularly significant in Malawi, since about 70% of the pregnant individuals suffer from gum disease.”

Malawi has one of the highest incidences of preterm birth worldwide, with preterm birth occurring in up to 20% of births, the researchers noted. Preterm birth is the leading cause of death worldwide for children under 5, the report noted. 

Valentine is leading another Malawi trial, the Prevention of Developmental Delay and Xylitol study. It follows 1,000 children born during the initial trial to study neurodevelopmental outcomes between 4 and 8 years of age. 

That study seeks to evaluate whether xylitol in pregnancy affects the children’s development, growth, hearing and vision. The study is important to ensure no long-term harm occurred to children exposed to xylitol, Valentine said. Those results are expected in 2027.

The researchers plan to test the xylitol-gum intervention in pregnancies in lower-resourced communities in the Seattle area, he added. 

---

Journal

Med

DOI

10.1016/j.medj.2024.10.016 

The worldwide economic effects of oral health conditions

 

Peer-Reviewed Publication

International Association for Dental, Oral, and Craniofacial Research

Alexandria, VA – The International Association for Dental, Oral, and Craniofacial Research (IADR) and the American Association for Dental, Oral, and Craniofacial Research (AADOCR) have announced the publication of a study in Journal of Dental Research that examines the overall effects of oral health on global, regional, and national economies.

The recent WHO Oral Health Resolution and the subsequent WHO Global Oral Health Action Plan highlight the key relevance of providing information on the economic impacts of oral conditions. The purpose of this study was to provide updated estimates for the global, regional and country-level economic impacts of oral conditions in 2019. Extending previously established methods, dental expenditures (costs for treatments) and productivity losses for five oral conditions (caries in deciduous & permanent teeth, periodontitis, edentulism, other oral diseases) were estimated for the year 2019.

“These findings demonstrate the enormous global economic burden that arises from oral diseases due to the costs of treatment and losses in productivity,” said JDR Editor-in-Chief Nick Jakubovics. “Oral diseases must be included in the upcoming United Nations High-Level Meetings on Non-Communicable Diseases and Universal Health Coverage.”

The estimated total worldwide economic impacts of dental diseases in 2019 were $710B, whereof $387B ($327B-$404B) due to direct costs and $323B ($186B-$460B) due to productivity losses for the five main oral conditions. Low Income countries spent an average of $0.52 ($0.22-$0.96) per capita on dental care, while High Income countries spent an average of $260 ($257-$268) per capita – a 500-fold difference. These findings suggest that the prevention and treatment of oral diseases continue to substantiate an enormous economic burden to individuals and society.

The comprehensiveness of estimates supersedes that of previous work as the primary information on direct costs was identified for a higher number of countries. The need for more and better routine reporting and monitoring of the economic impact of oral conditions is emphasized, particularly for the WHO Eastern Mediterranean and African regions. The relevance of such information is also highlighted by its inclusion in the first-ever WHO Global Oral Health Status Report and Global Strategy on Oral health 2023-2030. Given the persistently high economic burden of oral conditions, there is a key role for better prioritization of cost-efficient oral health programs as well as needs-responsive capacity planning.

Bacteria involved in gum disease linked to increased risk of head and neck cancer

 

More than a dozen bacterial species among the hundreds that live in people’s mouths have been linked to a collective 50% increased chance of developing head and neck squamous cell carcinoma (HNSCC), a new study shows. Some of these microbes had previously been shown to contribute to periodontal disease, serious gum infections that can eat away at the jawbone and the soft tissues that surround teeth.

Experts have long observed that those with poor oral health are statistically more vulnerable than those with healthier mouths to HNSCC, a group that includes the most common cancers of the mouth and throat. While small studies have tied some bacteria in these regions (the oral microbiome) to the cancers, the exact bacterial types most involved had until now remained unclear.

Led by researchers at NYU Langone Health and its Perlmutter Cancer Center, the new analyses looked at the genetic makeup of oral microbes collected from healthy men and women. Of the hundreds of different bacteria that are routinely found in the mouth, 13 species were shown to either raise or lower risk of HNSCC. Overall, this group was linked to a 30% greater likelihood of developing the cancers. In combination with five other species that are often seen in gum disease, the overall risk was increased by 50%.

“Our findings offer new insight into the relationship between the oral microbiome and head and neck cancers,” said study lead author Soyoung Kwak, PhD. “These bacteria may serve as biomarkers for experts to flag those at high risk,” added Kwak, a postdoctoral fellow in the Department of Population Health at NYU Grossman School of Medicine.

Previous investigations had uncovered certain bacteria in tumor samples of people already diagnosed with these cancers, says Kwak. Then, in a small 2018 assessment, the current research team explored how microbes in healthy participants may over time contribute to future risk of HNSCC.

Their latest report, publishing online Sept. 26 in the journal JAMA Oncology, is the largest and most detailed analysis of its kind to date, says Kwak. It is also among the first to examine whether common fungi, organisms like yeast and mold that, along with bacteria, make up the oral microbiome, might play a role in HNSCC. The new experiments found no such role for fungal organisms.

For the research, the team analyzed data from three ongoing investigations tracking 159,840 Americans from across the country to better understand how diet, lifestyle, medical history, and many other factors are involved in cancer. The data were gathered for the American Cancer Society Cancer Prevention Study II; the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; and the Southern Community Cohort Study.

Shortly after enrolling, participants rinsed with mouthwash, providing saliva samples that preserved the numbers and species of microbes for testing. Researchers then followed up for roughly 10 to 15 years to record any presence of tumors.

In the current study, the investigators analyzed bacterial and fungal DNA from the spit samples. Then, they identified 236 patients who were diagnosed with HNSCC and compared the DNA of their oral microbes with that of 458 randomly selected study subjects who had remained cancer-free. In their research, the team accounted for factors known to play a role, such as age, race, and how often they smoked cigarettes or drank alcohol.

“Our results offer yet another reason to keep up good oral-hygiene habits,” said study co-senior author Richard Hayes, DDS, MPH, PhD. “Brushing your teeth and flossing may not only help prevent periodontal disease, but also may protect against head and neck cancer,” added Hayes, a professor in the Department of Population Health at NYU Grossman School of Medicine and a member of its Perlmutter Cancer Center.

The researchers emphasized that their study was designed to identify correlations between risk of cancer and certain bacteria in the mouth, but not to establish a direct cause-and-effect link. That will require further research.

“Now that we have identified key bacteria that may contribute to this disease, we next plan to explore the mechanisms that allow them to do so and in what ways we can best intervene,” said study co-senior author Jiyoung Ahn, PhD. Ahn is a professor in the Departments of Population Health and Medicine at NYU Grossman School of Medicine and is the associate director for population research at its Perlmutter Cancer Center.

Ahn cautions that while the added risks from bacteria are concerning, overall cases of head and neck cancer remain fairly uncommon.