Most preventive antibiotics prescribed by dentists are unnecessary

A new study conducted by researchers at the University of Illinois at Chicago and published in JAMA Network Open has found that 81% of antibiotics prescribed by dentists - who are among the top prescribers in the U.S., accounting for about 10% of all antibiotic prescriptions - to prevent infections prior to dental visits are unnecessary.
The researchers, led by Katie Suda, associate professor of pharmacy systems, outcomes and policy at the UIC College of Pharmacy, say that this surprising finding highlights the need for improved antibiotic stewardship in dental practices, especially those located in the Western U.S., which were associated with the highest rates of unnecessary prescribing.
Using Truven, a national integrated health claims database, the researchers retrospectively analyzed dental visits occurring between 2011 and 2015. They compared antibiotic prescriptions -- which were dispensed prior to 168,420 dental visits -- to the number of high-risk cardiac patients who, per national guidelines, are the only patients recommended for antibiotics prior to a dental procedure.
They found that 81% of prescriptions did not align with the national guidelines and were provided for patients without high-risk cardiac conditions.
"Use of preventive antibiotics in these patients opens them up to the risks associated with antibiotic use -- increasing bacterial resistance and infections, for example -- when the evidence used to develop the guidelines suggests that the risks outweigh the benefits in most patients," said Suda, the corresponding author on the study.
The researchers also looked at dentists' antibiotic prescribing patterns by geography. They found that the Western U.S. and urban areas were more likely to have unnecessary prescribing. Among patients most likely to fill prescriptions for unnecessary antibiotics are those with prosthetic joint implants and those receiving clindamycin.
"These results point to trends by geography that are unexpected -- they are the opposite of what is seen in medical clinics -- and to an alarming tendency of dental providers to select clindamycin, which is associated with a higher risk of developing C. difficile infections when compared to some other antibiotics," Suda said.
UIC's Susan Rowan, a dentist, worked with Suda on the research.
"Dental providers are very thoughtful when they develop care plans for their patients and there are many factors that inform dentists' recommendations and the medications they prescribe, but this study shows that there is an opportunity for dentists to reevaluate if necessary and incorporate renewed commitments to antibiotic stewardship into their practices that limit preventive prescriptions to a small group of patients," said Rowan, executive associate dean and associate dean for clinical affairs at the UIC College of Dentistry. "I think dental providers should view this study, which is the first to look at preventive antibiotic prescribing for dental procedures and provide this type of actionable information, as a powerful call to action, not a rebuke."
The authors noted that because the study was limited to patients with commercial dental insurance and the analysis used a broad definition of high-risk cardiac patients, the findings may actually underestimate unnecessary prescribing of antibiotics.

US dentists out-prescribe UK dentists when it comes to opioids

Researchers from the University of Illinois at Chicago have found that dentists practicing in the U.S. write 37 times more opioid prescriptions than dentists practicing in England. And, the type of opioids they prescribe has a higher potential for abuse.
Their findings, which are reported in JAMA Network Open, suggest that measures to reduce opioid prescribing by dentists, who are among the top prescribers of opioids in the U.S., should be discussed by policymakers and professional associations.
The study was, in part, a collaboration between UIC's Colleges of Pharmacy and Dentistry, and the University of Sheffield.
UIC's Katie Suda, the corresponding author of the study, says that the degree to which prescribing patterns differ between dentists in the two countries, which have similar oral health and dental utilization, is eye-opening.
"To see such a difference between two groups of dentists in countries with similar oral health and use of dentists is an indicator that opioid prescribing practices in the U.S. warrant a second look," said Suda, associate professor of pharmacy systems, outcomes and policy at the UIC College of Pharmacy. "This study tells us that efforts to adopt national guidelines for treating dental pain and for promoting conservative opioid prescribing practices among dentists in the U.S. should be a priority and should be included as part of more comprehensive judicious opioid prescribing strategies."
To study dental provider opioid prescribing practices in the two countries, Suda and her colleagues analyzed nationally-representative databases from both countries of prescriptions dispensed from retail pharmacies, including community and mail service pharmacies, and outpatient clinic pharmacies in 2016, which is considered to be a peak point in the U.S. opioid crisis.
They found U.S. dentists wrote 37 times more opioid prescriptions in 2016 -- 1.4 million in the U.S. compared to only 28,000 in England. This finding remained even when the researchers adjusted for differences in population size and number of dentists.
They also found that U.S. dentists prescribed a much wider range of opioids, where dentists in England only prescribed one -- a codeine derivative called dihydrocodeine, which is the only opioid included in the formulary used by their National Health Service. In the U.S., the most commonly prescribed opioids were hydrocodone-based, followed by codeine, oxycodone and tramadol. One in ten opioids prescribed by U.S. dentists were opioids with a high potential for abuse and diversion, such as oxycodone and long-acting opioids. Dentists in England did not prescribe these opioids.
"Dentists need to be part of the opioid conversation," said co-author Dr. Susan Rowan, executive associate dean and associate dean for clinical affairs at the UIC College of Dentistry. "It is common for people to overlook dental issues until pain becomes severe and major interventions are needed. Pain killers are often an essential part of dental care and provider flexibility in choice is important, but this study shows us there is room for dental care providers to contribute to and inform abuse reduction programs.
"This data should be a wakeup call to individual dental practices and collaborative organizations of dental care providers to push the envelope towards greater efforts to reduce opioid prescribing or patients' potential for abuse," Rowan said.
"I was shocked to discover the high level of opioid prescribing of my U.S. dental colleagues. Particularly, when there is good evidence that NSAIDs and acetaminophen are as good or better than opioids for treating dental pain and don't cause the unpleasant side-effects, addiction and misuse problems associated with opioids," said co-author Dr. Martin Thornhill, professor of translational research in dentistry at the University of Sheffield. "UK dentists manage exactly the same pain problems as their U.S. colleagues and achieve high levels of patient satisfaction using NSAIDs and acetaminophen, without the need to resort to opioids."

The healing power of a smile: A link between oral care and substance abuse recovery

A new study links the benefits of comprehensive oral care to the physical and emotional recovery of patients seeking treatment for substance use disorder

University of Utah Health

IMAGE: The graphic shows the distribution of patients in the study. view more 

Credit: Glenn Hanson, University of Utah Health

Your smile, and associated oral health, may be a factor for successfully passing through the revolving doors of life. It is your first impression to a stranger, the closing argument to land a job and a major factor to achieving a good quality of life. For those who struggle with substance use disorder, oral health often falls off the precipice of self-care thereby seriously damaging interpersonal skills, while causing poor nutrition, increased oral and general infections and debilitating oral pain.
A team of researchers at the University of Utah School of Dentistry explored the effect of comprehensive oral care for a more holistic approach to substance use disorder treatment. Their work shows for the first time that participants who had their major oral health problems addressed by a dental professional stayed in treatment approximately two times longer and had a more than 80 percent increase in completing their substance abuse treatment program. The results of the study are available online May 20 in the Journal of the American Dental Association.
"There is a powerful synergism between oral health care and substance use disorder," said Glen Hanson, D.D.S., Ph.D., professor of Pharmacology and Toxicology and School of Dentistry at U of U Health and first author on the paper. "Those who received comprehensive dental care had a better quality of life as measured by substantial improvements in employment and drug abstinence as well as a dramatic decrease in homelessness."
While the study did not examine specific reasons for the different positive responses observed for the FLOSS participants compared to the controls, a statistical analysis supports the idea that the improvements in substance abuse treatment outcomes were associated with the comprehensive dental care and not to other variables such as gender, type of drug abused, treatment facility, or age.
Hanson and his team joined collaborators at two Salt Lake City substance use clinics, Odyssey House and First Step House, to develop the FLOSS (Facilitating a Lifetime of Oral Health Sustainability for Substance Use Disorder Patients and Families) program. While the project was designed to provide the next generation of dentists with the skill set to care for underserved populations, Hanson discovered the participants got much more than just an improved smile from the experience.
Between 2015 and 2017, the substance use treatment centers recruited patients for the study. First Step House allowed patients to self-select for dental care (158 males in dental and 862 males in control), while Odyssey House identified participants with major oral health problems and then randomly assigned those to treatment or control (70 males and 58 females in dental and 97 males and 45 females in control). Patients in the FLOSS program received care at the U of U Health School of Dentistry for treatments ranging from extractions to root canals, to restorations to dentures.
Hanson and his team conducted a retrospective study of the data to explore the role of FLOSS in helping patients completing their substance use programs.
After comprehensive dental care, the FLOSS participants, either self-selected or randomly selected, were more likely to continue and complete their substance use treatment program. Hanson and his colleagues believe that providing complete oral care as part of treating the whole patient, is critical to resurrecting self-esteem and restoring important body functions as an essential first step on the long path to recovery from drug abuse.
"The experience is life changing not only for the patients but also dental providers such as dental students who now know how their work can dramatically alter their patients' lives," Hanson said. "I think if we do the same thing for patients experiencing other chronic health problems, like diabetes, we could see similar positive results for treatment outcomes."

Protect protruding teeth from damage and long-term consequences

University of Adelaide

IMAGE: Children with their first or early adult set of teeth that stick out have an increased chance of damaging them, but the risk can be easily reduced without being prohibitively... view more 

Credit: The University of Adelaide

Children with their first or early adult set of teeth that stick out have an increased chance of damaging them, but the risk can be easily reduced without being prohibitively costly.
A study undertaken at the University of Adelaide of more than 50,000 children aged under 19 years published in the journal Dental Traumatology, confirms a direct link between the degree to which a young patient's teeth protrude and the chance of damaging them.
"Traumatic dental injuries have been identified as the fifth most prevalent disease or injury globally and their subsequent management is costly," says Dr Esma Dogramaci, Senior Lecturer in Orthodontics, the University of Adelaide.
"While the number of traumatic dental injuries have fallen over recent decades, they have significant physical, psychological and economic consequences.
"Young children up to the age of six years with teeth that stick out more than 3mm have over three times higher chance of trauma than children without protruding teeth.
Children over six years with teeth that protrude more than 5mm have over double the chance of trauma," says Dr Dogramaci.
Corrective orthodontic treatment of children's teeth isn't usually undertaken until all permanent adult teeth have come through - usually after the age of 12 years. However, an expensive visit to an orthodontist isn't essential to protect teeth that stick out.
"A dentist can easily measure how far a child's teeth stick out and recommend whether they should be fitted with a brace. They can apply simple braces which can reduce the prominence of protruding teeth and significantly reduce the chance of them being damaged," says Dr Dogramaci.
If children suck their thumb this may also cause the teeth to stick out so they should be discouraged from this habit as early as possible. Children should also wear a mouth guard to protect protruding teeth when playing sports.
"Early identification and protection of protruding teeth through regular dental check-ups reduces the chance of early problems becoming long-term dental issues," says Dr Dogramaci.
"If young teeth are broken or knocked out long-term issues may occur like the need for root canal treatment or even tooth loss, requiring a lifetime commitment for general dental treatment.
"Also, if orthodontic treatment is carried out on teeth that have previously suffered from trauma, further complications can occur during orthodontics that could lead to the loss of those teeth.
"The results of this study confirm that regular check-ups, particularly for children, are a must for good long-term dental health."