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."

Oral cancer detection by dentists is significantly on the rise

After examining data gathered over an 11-year period in a first-of-its-kind provincial study, University of Toronto clinician-scientist Marco Magalhaes has one vital message: dentists in Ontario are detecting more cases of oral cancer and pre-cancer than ever before -- and it's saving lives.
Magalhaes, lead author of the study that appears in the Journal of the American Dental Association, is an assistant professor at the University of Toronto's Faculty of Dentistry, and one of the oral pathologists at the Toronto Oral Pathology Service (TOPS). Operated by the Faculty of Dentistry, TOPS is one of the largest oral pathology services in Canada, which provides comprehensive evaluation of biopsy specimens -- the overwhelming majority of which are submitted by dentists.
For the study, Magalhaes looked at 63,483 biopsies submitted to the service between 2005 and 2015. "We wanted to look at the scope of oral biopsies performed by dentists, what they're seeing in practice," says Magalhaes of the study's design. The biopsy data from TOPS were then compared to numbers collected by the Ontario Cancer registry, Cancer Care Ontario, which tracks all reported cancers in the province.
Surprisingly, the data showed a steep rise in the overall numbers of carcinomas (oral cancers) and dysplasia (pre-cancerous lesions) detected by dentists.
Overall, 828 cases of oral cancer were diagnosed by the U of T oral pathology service between 2005 to 2015, along with 2,679 premalignant lesions. But over time, the percentage of oral cancer detection by oral health professionals rose significantly. In 2005, only 56 cases of oral cancer and 99 cases of oral epithelial dysplasia were detected through biopsy.
By 2015, though, the number of cancers detected through the biopsy service had nearly doubled, rising to 103 cases of oral cancer. Dysplasia cases more than tripled from 2005, rising to 374 cases.
"These numbers are important, because the number of diagnosed cases outpaced both the rise in population in Ontario and the increased number of dentists licensed in Ontario," says Magalhaes.
In fact, the number of cases detected at TOPS was significantly higher than the overall increase of oral cancers recorded in the province over that same period -- just 30 per cent -- compared to the 180 per cent rise at TOPS. Cancer Care Ontario identified a total of 9,045 cases of oral cancer between 2005 and 2015.
So what does it all mean? For one, argues Magalhaes, dentists in Ontario are playing an important role in detecting the deadly disease.
And more comprehensive training and continuing education programs for oral health professionals may be behind the dramatic rise in detection rates. While advanced oral cancers are fairly easy to detect, says Magalhaes, premalignant lesions and early cancer can be easy to miss without specialized training. Early detection of oral cancers, meanwhile, is "critical" to survival rates, he explains.
Calling the Toronto Oral Pathology service "extraordinary," Michael Glogauer, acting chief dentist at the Princess Margaret Cancer Centre and professor at the University of Toronto's Faculty of Dentistry, agrees that strong training is likely playing a role in the higher detection rates.
"The focus on oral cancer education thought the universities and continuing education in the area of cancer has led to the increased surveillance by dentists, and validates the focus that the dentists in this province are placing on this important health initiative," says Glogauer.
Tracking precancerous links
An added dimension of the data collected in this study is that researchers may learn to pinpoint which -- and how many -- precancerous lesions will, over time, turn cancerous. While the data of the study provide evidence that TOPS was involved in the diagnosis of approximately 10 per cent of all oral cancers in the province, it also demonstrates a dramatic increase in the number of precancerous lesions identified by these health care providers.
Importantly, the provincial cancer agency does not keep statistical data on precancerous lesions, making the TOPS biopsy data especially relevant in the hunt to discover which premalignant lesions will become cancers.
"This is the first time that we have assessed dysplasia detected by dentists over such a long period of time," says Magalhaes.
Early detection is key
Oral cancer survival rates have remained steady over the past several decades. What that means, says Magalhaes, is that "advancements in treatment have minimally improved survival rates." Yet, treated in its early stages, patients with oral cancer have the highest survival rates: around 80 per cent over five years. That statistic drops to approximately 30 per cent over five years when the cancer is detected at an advanced stage.
"This supports the fact that early detection really is the most important step here," Magalhaes adds. And, as the study suggests, regular check-ups at the dentist's office may be our best line of defense.

Dentists can be the first line of defense against domestic violence

The University of Arizona College of Medicine - Phoenix and Midwestern University have published an article to bring to light the important role dentists can play in identifying domestic violence victims.
Published April 11 in the Journal of Aggression, Maltreatment and Trauma, the article reports that as much as 75 percent of head and neck trauma associated with domestic violence occurs with oral injury. Researchers concluded that dentists are in the unique position to be the first line of defense in identifying evidence of assault, and then reporting potential cases of domestic violence.
"The overall purpose of the paper is to bring dentistry and its subspecialties into the conversation about traumatic brain injury (TBI), specifically in cases of domestic violence," said Midwestern University dental student Timothy Ellis, lead author of the study.
"In our society, and others around the world, domestic violence is more common than many would suspect. Survivors recount 'too many times to remember' that they were abused and blacked out or were struck in the head. Thus, oral and facial trauma may be treated or identified by dentists and dental sub-specialists, opening another avenue for patients to gain access to proper care or needed assistance."
Ellis and Jonathan Lifshitz, PhD, director of the Translational Neurotrauma Research Program at the UA College of Medicine - Phoenix, reported an estimated 41.5 million individuals who will experience some type of domestic violence during their lifetime, and 20.75 million will sustain a TBI. Of the victims that sustain a TBI, 8.3 million will live with some form of long-term physiological or psychological consequences of the injury, they said.
"This is a societal need and we have to call on all health care providers and mandatory reporters to join the fight," Dr. Lifshitz said. "This paper is creating additional touchpoints between victims and the health-care delivery system. It is an opportunity for dentists to be early detectors who can refer those individuals for follow-up care."
The oral biomarkers that could help dentists potentially identify domestic violence victims include tears, fractures, breaks and chips in the teeth and mouth that would be inconsistent with personal history and, therefore, raise the index of suspicion. Obvious signs of violence that may indicate brain injury include jaw or tooth fractures, trauma to nerves in the mouth and jaw, as well as damage to the nasal bone. Tooth discoloration, blunted roots and pulpal necrosis, which is the death of cells and tissues in the center of a tooth, also may be signs of a previous dental trauma warranting further investigation.
According to the publication, dentists receive little to no education about identifying and discussing domestic violence with potential victims, yet they may be the first and only health professional to evaluate a domestic violence victim.
"I have spoken with several dentists regarding the topic," Ellis said. "Many find it interesting, however, they have little experience. The most common answer I receive is that they had just never thought about it or believed that such a case would be more likely to present in a medical facility and thus, it does not cross their mind when interacting with patients on a daily basis. That said, many dentists are intrigued by the topic and the response has been positive. It is interesting that very stringent protocols exist in pediatric dentistry, but a large gap exists when dealing with teens, young adults and adults in general."
Sheri Brownstein, DMD, director of preclinical faculty at the Midwestern University College of Dental Medicine - Arizona and a co-author of the study, said that as a dentist, she always is sensitive to head and neck injuries and behaviors and how these may be a sign of domestic violence, but never thought of the oral biomarkers as they relate to traumatic brain injury and domestic violence.
"All dentists should be educated on the identification of potential injuries sustained as a result of domestic violence," she said. "As health-care providers, we are already obligated to report suspected abuse. I do not feel that this will add an undue burden to dentists."

Ellis said next steps may include collecting data from dentists to document oral biomarkers of injury. He continues these queries with the objective to help at least one patient and their situation.

Common oral infections in childhood may increase the risk of atherosclerosis in adulthood

The association between childhood oral infections and adulthood carotid atherosclerosis was observed in The Cardiovascular Risk in Young Finns Study, an ongoing prospective cohort.
"The observation is novel, since there are no earlier follow-up studies on childhood oral infections and the risk of cardiovascular diseases," says docent Pirkko Pussinen from the University of Helsinki.
More progressed oral infections and inflammations - endodontic lesions and periodontitis - are known to be associated with several cardiovascular risk factors and disease risk in adults. In adults periodontitis in particular has been studied extensively, and currently it is considered an independent risk factor for atherosclerotic vascular diseases. The treatment of periodontitis is also known to decrease cardiovascular risk factors.
The association between childhood oral infections and atherosclerosis was found in a study conducted at the University of Helsinki, Department of Oral and Maxillofacial Diseases, in collaboration with the national Cardiovascular Risk in Young Finns Study research group. The study was published in JAMA Network Open.
The study was initiated in 1980, when clinical oral examinations were conducted for 755 children aged 6, 9, and 12 years. The follow-up ended in 2007, when the carotid artery intima-media thickness was measured in an ultrasound examination of participants, who were then 33, 36, and 39 years old.
The follow-up was 27 years, and cardiovascular risk factors were measured at several time points. A cumulative exposure to the risk factor was calculated in both childhood and adulthood. The signs of oral infections and inflammation collected in the study included caries, fillings, bleeding on probing, and probing pocket depth.
THE MORE SIGNS OF ORAL INFECTIONS, THE HIGHER RISK FOR ATHEROSCLEROSIS From all children, 68%, 87%, and 82% had bleeding, caries, and fillings, respectively. There were no differences between the boys and the girls. Slight periodontal pocketing was observed in 54% of the children, and it was more frequent in the boys than in the girls. Only 5% of the examined mouths were totally healthy, whereas 61% and 34% of the children had one to three signs and four signs of oral infections, respectively.
"The number of signs associated significantly with the cumulative exposure to the cardiovascular risk factors in adulthood, but especially in childhood," says professor Markus Juonala from the University of Turku.
Both caries and periodontal diseases in childhood were significantly associated with carotid artery intima-media thickness in adulthood. Thickening of the carotid artery wall indicates the progression of atherosclerosis and an increased risk for myocardial or cerebral infarction.
The researchers emphasise, in conclusion: "Oral infections were an independent risk factor for subclinical atherosclerosis; and their association with cardiovascular risk factors persevered through the entire follow-up. Prevention and treatment of oral infections is important already in childhood."

Nursing, dental, and medical students train together to improve kids' oral health \

Team-based clinical experiences help health professionals develops skills for working together

New York University

Nursing, medical, and dental students can work as a team to improve their knowledge of pediatric oral health--and how to work with their fellow health professionals, finds new research led by NYU Rory Meyers College of Nursing. The study appears in the Journal of Dental Education.
Cavities are the most common chronic childhood disease. Over the past two decades, reports and policies have called for pediatric primary care providers to incorporate oral health into their well visits, including screening and referring children to dentists. Despite these efforts, many primary care providers are not integrating oral health into patient visits, and some report feeling unprepared or uncomfortable in this role.
To improve interprofessional skills and collaboration between primary care and dental providers, NYU Meyers' Oral Health Nursing Education and Practice (OHNEP) program-which works to help nurses and other health professionals incorporate oral health into patient care--developed an innovative pediatric oral health clinical experience.
In the interprofessional experience, family nurse practitioner, medical, and dental students work as a team to assess patients. Together they review a patient's chart, take a patient's medical and dental history, perform an oral assessment, apply fluoride varnish, and educate children and parents. Students also learn to identify the connection between oral health and overall health--for instance, how certain diseases or medications can affect oral health. The goal is to increase the oral health knowledge and skills of non-dental primary care providers while boosting dental students' knowledge about the link between oral and systemic health.
"Collaborative, workplace-ready students are valuable assets to any clinical team. Our goal is for team-based, whole person care to become the norm for promoting children's oral health and preventing cavities," said Erin Hartnett, DNP, PPCNP-BC, CPNP, director of OHNEP at NYU Meyers and the study's lead author.
Over three semesters, a total of 162 family nurse practitioner, dental, and medical students participated in this interprofessional experience at a New York City hospital. Students completed surveys before and after their participation to evaluate whether their interprofessional competencies changed.
The researchers found that all students had significantly improved interprofessional competency scores after the team-based experience. This includes improvements in important factors for working with other professionals, such as communication, collaboration, conflict management, team functioning, and using a patient-centered approach.
"Our findings suggest that a team-based, clinical approach can be an effective strategy to help health professional students develop interprofessional competencies," said Judith Haber, PhD, APRN-BC, FAAN, the Ursula Springer Leadership Professor in Nursing at NYU Meyers, executive director of OHNEP, and the study's coauthor.
In addition to Hartnett and Haber, study authors include Peter Catapano of Bellevue Hospital Center, NYU School of Medicine, and NYU College of Dentistry; Nancy Dougherty, Amr Moursi, and Courtney Chinn of NYU College of Dentistry; Ramin Kashani of NYU College of Dentistry and Bellevue; Cindy Osman of NYU School of Medicine and Bellevue; and Abigail Bella of NYU Meyers.