Is it time US dentistry ended its opioid dependence?

Rural-urban differences in dental opioid prescribing among adolescent/young adult and adult Medicaid beneficiaries

Introduction

There are ongoing concerns about opioid prescribing for surgical and non-surgical dental needs among adolescent/young adult and adult patients. Although there are known differences in the overall opioid prescription rates in rural areas compared to urban areas, the contribution of dental opioid prescriptions is still unclear. This study aims to examine the factors associated with receiving an opioid prescription following a dental visit.

Materials and methods

This cross-sectional study utilized the 2021 Centers for Medicare & Medicaid Services unredacted Transformed Medicaid Statistical Information System Analytic Files to examine Medicaid and CHIP adolescent/young adult beneficiaries aged 12-20 and adults aged 21-64 who are non-dually eligible for Medicare and had a dental visit in 2021. Multilevel logistic regression models were used to predict the odds of receiving a dental opioid prescription.

Results

The results of the adolescent/young adult models show that for every percentage point increase in the percentage of non-Hispanic Black residents in a county, the odds of receiving a dental opioid prescription increase by 0.8% in rural areas. However, with every percentage point increase in the Hispanic population, the odds of receiving a dental opioid prescription decrease by 0.3% in rural areas and 0.7% in urban areas. The adult models show that compared to non-Hispanic white beneficiaries, non-Hispanic Black beneficiaries are 8% more likely to receive a dental opioid prescription if they live in rural areas and 18% more likely if they live in urban areas, while all other racial and ethnic groups are significantly less likely to receive a dental opioid prescription. With every unit increase in the concentrated disadvantage index, the odds of receiving a dental opioid prescription increase by 17% among rural adults and 24% among urban adults.

Discussion

Our findings on rural-urban disparities in opioid prescriptions suggest that prescription patterns in dental settings are significant and inequitable across various beneficiary- and county-level factors and areas of residence. These variations in prescription patterns highlight the known disparities in access to preventive dental care and the need for targeted interventions to address the healthcare needs of rural residents.

The Nature of Adverse Events in Dentistry

OBJECTIVES

Learning from clinical data on the subject of safety with regards to patient care in dentistry is still largely in its infancy. Current evidence does not provide epidemiological estimates on adverse events (AEs) associated with dental care. The goal of the dental practice study was to quantify and describe the nature and severity of harm experienced in association with dental care, and to assess for disparities in the prevalence of AEs.

METHODS

Through a multistaged sampling procedure, we conducted in-depth retrospective review of patients' dental and medical records.

RESULTS

We discovered an AE proportion of 1.4% (95% CI, 1.1% to 1.8). At least two-thirds of the detected AEs were preventable. Eight percent of patients who experienced harm due to a dental treatment presented only to their physician and not to the dentist where they originally received care.

CONCLUSIONS

Although most studies of AEs have focused on hospital settings, our results show that they also occur in ambulatory care settings. Extrapolating our data, annually, at least 3.3 million Americans experience harm in relation to outpatient dental care, of which over 2 million may be associated with an error.

PRACTICAL IMPLICATIONS

Measurement is foundational in enabling learning and improvement. A critical first step in preventing errors and iatrogenic harm in dentistry is to understand how often these safety incidents occur, what type of incidents occur, and what the consequences are in terms of patient suffering, and cost to the healthcare system.

Facts and trends in dental antibiotic and analgesic prescriptions in Germany, 2012-2021

OBJECTIVES

The study aims to overview German dentists' development of antibiotic and analgesic prescriptions from 2012 to 2021.

MATERIALS AND METHODS

A longitudinal database analysis was performed based on the annual reports of the "Research Institute for Local Health Care Systems" (WIdO, Berlin).

RESULTS

From 2012 until 2021, dental antibiotic prescriptions fell by 17.9%. In contrast, the dental proportion of antibiotic prescriptions compared to all antibiotic prescriptions in Germany increased from 9.1 to 13.6%. Aminopenicillins enhanced their share from 35.6 to 49.4%, while clindamycin prescriptions declined from 37.8 to 23.4%. The proportion of ibuprofen prescriptions significantly increased from 60.4% in 2012 to 79.0% in 2021.

CONCLUSIONS

Since 2013, the most frequently prescribed antibiotic by German dentists has been amoxicillin reaching nearly half of all dental antibiotic prescriptions in 2021. Simultaneously, the proportion of clindamycin has steadily decreased, but the level is still high compared to international data. During the past decade, ibuprofen as a first-line analgesic in German dentistry was continuously gaining in importance.

CLINICAL RELEVANCE

Aminopenicillins have the best risk-benefit balance in dentistry, but the use of antibiotics generally must be limited only to cases of severe infections or compromised patients. Pre-existing diseases or permanent medications should always be considered when choosing an analgesic.

Post-Procedure Analgesic Management

During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.

Association between the COVID-19 outbreak and opioid prescribing by U.S. dentists

BACKGROUND

U.S. data on opioid prescribing by dentists are limited to 2019. More recent data are needed to understand the effect of the COVID-19 outbreak on dental opioid prescribing, characterize current practices, and determine if dental opioid stewardship initiatives are still warranted.

OBJECTIVE

To evaluate the association between the COVID-19 outbreak and the rate of opioid prescribing by U.S. dentists.

METHODS

During February-April 2023, the authors conducted a cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which reports 92% of prescriptions dispensed in U.S. retail pharmacies. The authors calculated the monthly dental opioid dispensing rate, defined as the monthly number of dispensed opioid prescriptions from dentists per 100,000 U.S. individuals, during January 2016-February 2020 and June 2020-December 2022. To prevent distortions in trends, data from March-May 2020, when dental opioid dispensing declined sharply, were excluded. Using linear segmented regression models, the authors assessed for level and slope changes in the dental opioid dispensing rate during June 2020.

RESULTS

Analyses included 81,189,605 dental opioid prescriptions. The annual number of prescriptions declined from 16,105,634 in 2016 to 8,910,437 in 2022 (-44.7%). During January 2016-February 2020, the dental opioid dispensing rate declined -3.9 (95% CI: -4.3, -3.6) per month. In June 2020, this rate abruptly increased by 31.4 (95% CI: 19.3, 43.5) and the monthly decline in the dental opioid dispensing rate slowed to -2.1 (95% CI: -2.6, -1.6) per month. As a result, 6.1 million more dental opioid prescriptions were dispensed during June 2020-December 2022 than would be predicted had trends during January 2016-February 2020 continued.

DISCUSSION

U.S. dental opioid prescribing is declining, but the rate of this decline slowed after the COVID-19 outbreak. Findings highlight the continued importance of dental opioid stewardship initiatives.

Dental Pain Medication Prescriptions in Minas Gerais, Brazil (2011-2021): A Time-Series Analysis

To describe trends of dentist-prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, from January 2011 to December 2021, as well as to examine the relationship between these trends and characteristics of public oral health services in Minas Gerais, Brazil. In this time-series analysis, all drugs were classified according to the Anatomical Therapeutic Chemical classification system. Drugs categorized as NSAIDs (M01A), and other analgesics and antipyretics (N02B) were included for analysis. The outcome was the number of Defined Daily Doses (DDDs)/1000 inhabitants/year for NSAIDs and analgesics in each town. Covariates referred to characteristics of public oral health services, such as coverage, estimates of dental procedures, and frequency of toothache. Linear time-series regression models were used to determine the influence of covariates on the outcome. Overall, there were 58,482 prescriptions of NSAIDs recorded in thirty-eight towns, while 47,499 prescriptions of analgesics in forty-three towns. For each year, there was a 0.38 (p < 0.001), and 0.28 (p < 0.001) increase in the average log of DDD/1000 inhabitants/year for NSAIDs and analgesics, respectively. A positive association was detected between toothache (p < 0.001) and the prescription of NSAIDs. Over the eleven years, there was a general rising trend in the prescriptions. Toothache was the only characteristic of public oral health services associated with the prescription rates of NSAIDs, implying that as the frequency of toothaches increase, so do the prescriptions of NSAIDs in the studied towns.

The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study

BACKGROUND

Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship.

OBJECTIVES

The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry.

METHODS

We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes.

RESULTS

Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05).

CONCLUSION

The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign.

Opioids and older adults: Increasing trends in opioid usage in a dental population compared to a National Database (NHANES)

Aim

To examine self‐reported opioid prevalence at a dental school clinic for patients ≥65 years old as compared to national data, comparing gender, ethnicity/race and older adult age groupings.

Methods and results

Self‐reported prescription opioid medication use was extracted from the medical record for dental patients ≥65 years old who visited the school's general dental clinic (GDC) in 2012 or 2017. This data was compared to the National Health and Nutrition Examination Survey (NHANES) data for 2011–2012 and 2017–18. There was a significant increase in prevalence of opioid use in adults ≥65 between 2012 (4.5%) and 2017 (6.5%) and for ages 65–79 (from 4.7% to 6.3%) and ≥80 (3.4% to 7.9%), women (4.8% to 7.0%), and African Americans (4.7% to 8.4%) in the GDC. Older adults at the GDC reported less opioid use than the NHANES national average for both periods no matter the gender or the age with variable results for race/ethnicity.

Conclusion

The prevalence of older adults taking opioids in our general dental school clinic population increased significantly in 2017 as compared to 2012 but was lower than the national average for the respective periods. Awareness of existing opioid usage in older adult patients and its higher adverse risk potential is critical when prescribing analgesics for dental pain for this age group.

Effectiveness of online training of first and second year AEGD residents in identifying, referring, and managing patients at-risk for substance use and opioid disorders

BACKGROUND AND OBJECTIVES

Dentists have contributed greatly to the opioid epidemic, dispensing roughly 8.6% of opioids totaling over 18 million prescriptions in a 12-month period from July 2016 to June 2017 and report educational gaps regarding screening techniques for substance misuse and an unfamiliarity with available referral resources. The purpose of this study was to determine the knowledge and comfort level of residents in identifying, referring, and managing patients who are at risk for opioid use or substance use disorder in the dental setting before and after an online case-based training course.

METHODS

Thirty-five first year (PGY1) and 11 second year (PGY2) advanced education in general dentistry (AEGD) residents participated in an online training course that aimed to assess knowledge in the domains of identifying, referring, and managing patients at risk for substance abuse disorder and opioid use in an academic setting. There were nine subdomains within the three major domains that further assessed resident comfort and knowledge. Before and after training, data were collected and analyzed.

RESULTS

Analysis of the results indicated that (1) the training modules increased resident comfort in identifying (p = 0.011), referring (p = 0.032), and managing (p = 0.002) patients at risk for opioid substance use. (2) PGY1 residents benefited more than PGY2 residents in identifying (p = 0.034) and the manage domains (p < 0.001). (3) Residents viewed the module quality, usefulness, and applicability favorably. Further analysis of the nine subdomains is presented.

CONCLUSION

Our study suggests that dental curricula would benefit from incorporating training of residents in identifying, referring, and managing patients at risk for substance use disorder and opioid use.

Patient, Provider Type, and Procedure Type Factors Associated with Opioid Prescribing by Dentists in a Health Care System

Introduction

Reports examining opioid prescribing for dental conditions are limited and do not examine patient-level factors. This study examines the association of patient age, sex, race, ethnicity, Medicaid coverage, and the need for an interpreter in addition to procedure type and dental provider type with receipt of an opioid prescription in dental care settings within a large health system.

Materials and Methods

This study was conducted utilizing data from the electronic health record of HealthPartners, a large dental practice embedded within a health care system. The analytic sample consisted of all 169,173 encounters from 90,487 patients undergoing a dental procedure in the baseline period (9/1/2018 to 8/30/2019), prior to implementing a clinical trial to de-implement opioids in dentistry.

Results

Opioids were prescribed at 1.9% of all 169,173 encounters and rates varied by patient factors, procedure category, and provider type. Opioid prescriptions were most likely for extraction encounters (25.9%). In a multivariable analysis of 8760 extraction encounters, all patient age groups were more likely than those age 66+ to receive an opioid prescription, particularly those age 18–25 (OR=6.94). Patients having a complex rather than simple extraction were more likely to receive an opioid prescription (OR=6.31) and those seen by an oral surgeon rather than a general dentist (OR=9.11) were more likely to receive an opioid prescription. Among 108,748 encounters with a diagnostic procedure, opioid prescribing was more likely among male than female patients (OR=1.20), Black patients relative to White (OR=1.69), patients with Medicaid coverage (OR=1.86), and patients seeing an oral surgeon rather than a general dentist (OR=27.81).

Conclusion

Opioid prescribing rates vary considerably depending on procedure type. Patterns of associations between patient factors and opioid prescribing also vary considerably across procedure type. To understand which patient groups are more at risk of being prescribed opioids, it is essential to consider the procedures they are receiving.

Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond

Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management. The learning objectives for this conference proceedings were: Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.

Opioids in oral surgery: preliminary findings between Birmingham, UK and Boston, US

Aims This study aims to review ways in which UK and US practitioners manage post-operative dental pain following oral surgery procedures, focusing on the use of opioids in Boston, US and Birmingham, UK.Methods An anonymous online questionnaire was distributed to clinicians from either Birmingham Dental Hospital, UK and Harvard School of Dental Medicine or Boston University School of Dental Medicine, US. They were invited to fill this out via email link or in person using a tablet provided. Information was collected regarding age, years of experience, area of practice, area of undergraduate training, gender and levels of oral surgery activity. Participants were presented with six clinical scenarios and asked to indicate how they would achieve post-operative analgesia for each.Results A total of 44 responses were received, 22 from each city, including 27 males and 17 females. Fifty-five percent of respondents carried out at least ten weekly oral surgery procedures, with 52% having more than ten years' experience. Forty-one percent were aged greater than 40 years, with 32% less than 30. Boston dentists were 2.1 times (P = 0.016) more likely to opt for opioids than Birmingham dentists. Both cohorts were more likely to choose opioids for invasive surgeries involving flap procedures compared to simple extractions. Among the cases where UK respondents opted for opioids, codeine was chosen in 100% of cases compared to 9% for the US cohort, where the remainder chose more potent opioids (oxycodone, hydrocodone and tramadol).Conclusions Results of this preliminary study show that Boston practitioners were likely to opt for opioids in a higher proportion of cases (19.84%) than Birmingham practitioners (9.42%). Reasons for the discrepancies could be related to how practitioners are trained, patient expectations on pain relief and health policy in the two countries. Dental prescriptions have contributed to the US opioid epidemic and their decreased use will be important in combatting the crisis.

Prescriptions of analgesics and anti-inflammatory drugs in municipalities from a Brazilian Southeast state

The objective of this study was to describe dental prescriptions of non-steroidal anti-inflammatory drugs (NSAID), opioids, and analgesics dispensed by the Brazilian National Health System (BNHS, SUS in Portuguese) of a Southeastern state from January to December 2017, and to analyze their association with socioeconomic and oral health care services' characteristics at municipal level. Data were collected from the Brazilian Integrated Pharmaceutical Care Management System. Medicines were grouped according to the Anatomical Therapeutic Chemical Classification System. The total number of Defined Daily Doses (DDD) and DDD per 1,000 inhabitants (inhab.) per year were presented and compared between groups of municipalities. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25.0. The total number of NSAID, opioids, and analgesics prescriptions was 70,747 and accounted for 354,221.13 DDD. The most frequently prescribed medicine was ibuprofen (n = 24,676; 34.88%). The number of dental practitioners in the BNHS per 1,000 inhab. (p < 0.001), first dental appointment coverage (p = 0.010), oral health teams per 1,000 inhab. (p=0.022), and the proportion of rural population (p = 0.014) were variables positively associated with the number of DDD of NSAID per 1,000 inhab. per year. Bolsa Família program coverage per 1,000 inhab. (p = 0.022) was negatively associated with NSAID prescription. Regarding analgesics, first dental appointment coverage (p=0.002) and Bolsa Família program coverage per 1,000 inhab. (p = 0.012) were positively associated with DDD per 1,000 inhab. per year. In conclusion, dental prescriptions of analgesics and NSAID in the BNHS were associated with socioeconomic and oral health care services' characteristics.

Orofacial pain education in dentistry: A path to improving patient care and reducing the population burden of chronic pain

Dentists stand in an optimal position to prevent and manage patients suffering from chronic orofacial pain (OFP) disorders, such as temporomandibular disorders, burning mouth syndrome, trigeminal neuralgia, persistent idiopathic dentoalveolar pain, among others. However, there are consistent reports highlighting a lack of knowledge and confidence in diagnosing and treating OFP among dental students, recent graduates, and trained dentists, which leads to misdiagnosis, unnecessary costs, delay in appropriate care and possible harm to patients. Education in OFP is necessary to improve the quality of general dental care and reduce individual and societal burden of chronic pain through prevention and improved quality of life for OFP patients. Our aims are to emphasize the goals of OFP education, to identify barriers for its implementation, and to suggest possible avenues to improve OFP education in general, postgraduate, and continuing dental education levels, including proposed minimum OFP competencies for all dentists. Moreover, patient perspectives are also incorporated, including a testimony from a person with OFP. General dentists, OFP experts, educators, researchers, patients, and policy makers need to combine efforts in order to successfully address the urgent need for quality OFP education.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

This comprehensive review of the 2019 restorative dental literature is offered to inform busy dentists regarding remarkable publications and noteworthy progress made in the profession. Developed by the Scientific Investigation Committee of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to 1 of 8 sections of the report: (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information likely to influence day-to-day dental treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source material when greater detail is desired. As the profession moves toward evidence-based clinical decision-making, an incredible volume of potentially valuable dental literature continues to increase. It is the intention of this review and its authors to provide assistance in negotiating the extensive dental literature published in 2019. It is our hope that readers find this work useful in the clinical management of dental patients.

Pain after mandibular ramus block harvesting and lateral ridge augmentation with and without involvement of platelet-rich fibrin: a randomized controlled trial

The purpose of this study was to evaluate pain after mandibular ramus block harvesting and lateral ridge augmentation. Autogenous bone block grafts were covered with platelet-rich fibrin (PRF) membranes (test group) or deproteinized bovine bone and a resorbable collagen membrane (control group). This study included 27 partially edentulous patients (test = 14, control = 13) with an indication for bone block augmentation before staged implant placement. Postoperative methylprednisolone (32 mg, day 1) and analgesics comprising ibuprofen (400 mg, four times daily) and paracetamol (1 g, four times daily) were prescribed for 1 week. Pain was recorded by the patient on a 100-mm visual analogue scale (VAS), hourly on the day of surgery and daily for the following 7 days. The average (mean ± standard deviation) maximum pain score over the whole observation period was similar in the test (13.6 ± 13.5) and control (21.0 ± 19.9) groups (P = 0.17). In conclusion, harvesting of a mandibular ramus block and lateral ridge augmentation, in conjunction with the pharmacological protocol described, is characterized by low postoperative pain. Adding PRF membranes to the surgical site generally resulted in slightly lower pain perception, although a statistically significant difference between the test and control groups was only identified on day 1 postoperative.

Improvement of dental prescribing practices using education and a prescribing tool: A pilot intervention study

AIMS

Antibiotic resistance is a global public health problem. Around 55% of dental antibiotic prescribing is deemed inappropriate. The aim of this multimodal interventional pilot study was to assess the effect on prescribing of education and a dentally designed prescribing website.

METHODS

Twenty-six dentists were recruited for the 12-week study using a pre-post design. Dentists self-recorded their prescribing of antibiotics, analgesics and anxiolytics for 6 weeks. After dentists were provided education and website access, they recorded their prescribing for a further 6 weeks. Four outcomes were measured comparing the prescribing before and after the intervention: (i) the number of inappropriate indications for which antibiotics were prescribed; (ii) the number of prescriptions; (iii) accuracy of the prescriptions according to the Australian therapeutic guidelines; and (iv) the confidence of practitioners towards the prescribing website. Participants were interviewed for feedback.

RESULTS

There was a substantial reduction of 44.6% in the number of inappropriate indications for which antibiotics were prescribed after the intervention and a decrease of 40.5% in the total number of antibiotics. Paracetamol with codeine substantially reduced by 56.8%. For the 3 most commonly prescribed antibiotics (amoxicillin, phenoxymethylpenicillin and metronidazole), there was the improvement in the accuracy of the prescriptions ranging from 0-64.7 to 74.2-100%.

CONCLUSION

This pilot study showed the intervention of targeted education and the prescribing tool was effective in improving dental prescribing, knowledge and confidence of practitioners, as well as providing an effective antibiotic stewardship tool. This context-specific intervention shows substantial promise for implementation into dental practice.

Behavior Change Following Pain Neuroscience Education in Middle Schools: A Public Health Trial

Chronic pain and the opioid epidemic need early, upstream interventions to aim at meaningful downstream behavioral changes. A recent pain neuroscience education (PNE) program was developed and tested for middle-school students to increase pain knowledge and promote healthier beliefs regarding pain. In this study, 668 seventh-grade middle-school students either received a PNE lecture (n = 220); usual curriculum school pain education (UC) (n = 198) or PNE followed by two booster (PNEBoost) sessions (n = 250). Prior to, immediately after and at six-month follow-up, pain knowledge and fear of physical activity was measured. Six months after the initial intervention school, physical education, recess and sports attendance/participation as well as healthcare choices for pain (doctor visits, rehabilitation visits and pain medication use) were measured. Students receiving PNEBoost used 30.6% less pain medication in the last 6 months compared to UC (p = 0.024). PNEBoost was superior to PNE for rehabilitation visits in students experiencing pain (p = 0.01) and UC for attending school in students who have experienced pain > 3 months (p = 0.004). In conclusion, PNEBoost yielded more positive behavioral results in middle school children at six-month follow-up than PNE and UC, including significant reduction in pain medication use.

Pharmacological management of pain after periodontal surgery: a systematic review with meta-analysis

OBJECTIVES

To assess and compare the pharmacological effect of different drugs on pain relief after periodontal surgery.

MATERIALS AND METHODS

Five databases were searched up to September 2019. The eligible studies comprised randomized clinical trials, involving only adult individuals that received any periodontal surgery and presenting two distinct groups of therapeutic regimens to control postoperative pain. Placebo groups could be included. The risk of bias was assessed with the RoB 2 Cochrane tool and the GRADE system. Meta-analyses were performed using different follow-up and drug comparisons.

RESULTS

Overall, 2398 studies were identified, of which 35 were included. Low risk of bias was determined for the majority of the studies. The meta-analyses showed that the comparison of dexamethasone or non-steroidal anti-inflammatory drugs (NSAID) versus placebo favored the use of both interventions in a follow-up of 1 to 8 h for open flap procedures (OFP). However, no statistical difference was found for the comparison between NSAID and dexamethasone for OFP.

CONCLUSIONS

Patients may benefit from several pharmacological schemes for pain relief after periodontal surgeries. However, due to the high heterogeneity among studies, no fixed pharmacological protocol could be proposed.

CLINICAL RELEVANCE

There is not enough evidence to recommend one therapeutic scheme. However, untreated pain is harmful to the patients and it is not advisable.

Opioid Prescribing in Dental Practice: Managing Liability Risks

Dentistry should be proud of its history of providing responsible pain relief, as well as becoming more cautious in prescribing opioid medications when other safer pharmacologic options exist. Our training directs us to first eliminate the source of dental pain and prescribe analgesics only as adjunctive relief. Prescriptions must be written for a legitimate dental purpose and for a patient of record. Through self-regulation, the dental profession must continue to establish pain management guidelines based on scientific evidence and clinical experience to avoid further regulatory action restricting our prescribing privileges, which remain one of our most powerful therapeutic tools.