Patient Values and Preferences for Managing Acute Dental Pain Elicited through Online Deliberation

INTRODUCTION

Patient values and preferences (PVP) are among multiple sources of information panelists synthesize when developing clinical practice guidelines (CPG). Patient and public involvement (PPI) can be critical for learning PVP; however, the methodology for engaging patients in CPG development is lacking. Deliberative engagement is effective for obtaining public views on complex topics that require people to consider ethics, values, and competing perspectives.

OBJECTIVE

Elicit comprehensive understanding of PVP concerning oral analgesics for managing acute dental pain consecutive to toothache and simple and surgical dental extractions, with consideration of associated outcomes, both desirable and undesirable.

METHODS

Multistage engagement involving 2 electronic surveys and a 90-min online small group deliberative engagement. Adults who have experienced acute dental pain deliberated about 3 hypothetical scenarios stratified according to expected pain intensity, completed a postdeliberation survey, and validated a PVP statement developed by researchers based on review of qualitative data from deliberations and quantitative data from surveys.

RESULTS

Participants affirmed the PVP statement reflected their small group deliberations and their individual views. Most indicated that pain relief is critical to deciding which pain relief medicine they would want regardless of expected pain level. Most also identify as critical concerns about substance abuse or misuse, although many believe it unlikely that they will experience these outcomes over the brief prescription timeframe for acute dental pain. Participants identified agency in decision-making, consultation including "better communication" of options, and treatment actions tailored to life circumstances as key values.

CONCLUSIONS

Participants preferred nonprescription and nonopioid pain relief options. As expected pain levels increased, more participants expressed willingness to accept opioids, but more also mentioned rescue analgesia as a third outcome critical to decision-making. Online deliberative method provided opportunities for obtaining informed perspectives. Guideline developers and policymakers may find online deliberations useful for eliciting PVP related to health outcomes.

KNOWLEDGE TRANSFER STATEMENT

Study results informed the US Food and Drug Administration-funded clinical practice guideline on the management of acute dental pain. Findings may be a resource for clinicians in decision-making conversations with patients regarding expectations for pain relief and positive and negative outcomes of differing pain relief medications. Further research should pursue applicability of online deliberative engagement as a method to elicit patient values and preferences.

Evidence-Informed Oral Health Policy Making: Opportunities and Challenges

Despite a clear need for improvement in oral health systems, progress in oral health systems transformation has been slow. Substantial gaps persist in leveraging evidence and stakeholder values for collective problem solving. To truly enable evidence-informed oral health policy making, substantial "know-how" and "know-do" gaps still need to be overcome. However, there is a unique opportunity for the oral health community to learn and evolve from previous successes and failures in evidence-informed health policy making. As stated by the Global Commission on Evidence to Address Societal Challenges, COVID-19 has created a once-in-a-generation focus on evidence, which has fast-tracked collaboration among decision makers, researchers, and evidence intermediaries. In addition, this has led to a growing recognition of the need to formalize and strengthen evidence-support systems. This article provides an overview of recent advancements in evidence-informed health policy making, including normative goals and a health systems taxonomy, the role of evidence-support and evidence-implementation systems to improve context-specific decision-making processes, the evolution of learning health systems, and the important role of citizen deliberations. The article also highlights opportunities for evidence-informed policy making to drive change in oral health systems. All in all, strengthening capacities for evidence-informed health policy making is critical to enable and enact improvements in oral health systems.

Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis

This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.

Effect of antibiotic prophylaxis for preventing infectious complications following impacted mandibular third molar surgery. A randomized controlled trial

Background

The objective of this study was to determine the effect of antibiotic prophylaxis in preventing postoperative infections after extraction of impacted mandibular third molars.

Material and Methods

A Parallel-group, randomized, blind, placebo-controlled trial was performed. 154 patients were randomly allocated to 2 groups; experimental (n=77) receiving 2g amoxicillin 1 hour prior to surgery and control (n=77) receiving placebo. Primary outcome was postoperative infections and secondary outcome was the need for rescue analgesia.

Results

4.5% of patients developed postoperative infections, five patients of the control group (4 alveolar osteitis, 1 surgical site infection) and two of the experimental group (1 alveolar osteitis, 1 surgical site infection). Difference between groups was not statistically significant, RR=0.4 (95%CI 0.08-1.99, 𝘱=0.41) NNTB=26. Rescue analgesia intake was significantly higher in the control group (41 vs 18 patients of experimental group) RR=0.49 (95%CI 0.32-0.75, 𝘱<0.05) NNTB=3.

Conclusions

The use of 2g amoxicillin 1 hour before surgery was not effective in significantly reducing the risk of postoperative infections from impacted mandibular third molars extraction, when compared to placebo. Nevertheless, antibiotic prophylaxis was associated with a reduced need for rescue analgesia.

Key words:Antibiotic prophylaxis, third molar, tooth extraction, impacted tooth, dry socket, surgical wound infection, oral surgery.

Teledentistry and mHealth for Promotion and Prevention of Oral Health: A Systematic Review and Meta-analysis

The dental profession has experienced a dramatic acceleration in the use of communication systems and information-based technologies over recent years, originating new paradigms for the prevention and promotion of oral health. The purpose of this systematic review was to determine the effect of teledentistry-based (telematic) strategies, reported in randomized controlled trials and quasi-randomized trials, with a focus on oral health prevention and promotion-related outcomes in patients of all ages. We searched Medline via PubMed, SCOPUS, and Web of Science from inception until August 2020, regardless of the language of publication. We selected studies for inclusion and conducted data extraction, assessed risk of bias (Cochrane tool), and evaluated the certainty of the evidence (GRADE approach) in duplicate and independently. Out of 898 potentially eligible references, we selected 43 for full-text screening, of which 19 studies proved eligible: 18 randomized controlled trials and 1 quasi-randomized study. Virtual interventions were mostly asynchronous via apps (n = 9), text messages (n = 9), or computer-aided learning (n = 1). The use of teledentistry as compared with conventional strategies may result in a large reduction in the plaque index (standardized mean difference, -1.18; 95% CI, -1.54 to -0.82; I² = 92%; low certainty) and will likely result in a large reduction in the gingival index (standardized mean difference, -2.17; 95% CI, -3.15 to -1.19; I² = 97%; moderate certainty) and in the incidence of white spot lesions (risk ratio, 0.48; 95% CI, 0.35 to 0.66; I² = 0%; moderate certainty), with an increased effect over time. Evidence suggests that teledentistry, particularly mHealth (messages and apps), is a promising clinical tool for preventing and promoting oral health, especially under the accelerated virtualization of dentistry. Future studies should include a broader spectrum of the population, including adults and elders, to better inform policy and implementation of teledentistry (PROSPERO: CRD42020192685).

Improving Caries Risk Prediction Modeling: A Call for Action

Dentistry has entered an era of personalized/precision care in which targeting care to groups, individuals, or even tooth surfaces based on their caries risk has become a reality to address the skewed distribution of the disease. The best approach to determine a patient's prognosis relies on the development of caries risk prediction models (CRPMs). A desirable model should be derived and validated to appropriately discriminate between patients who will develop disease from those who will not, and it should provide an accurate estimation of the patient's absolute risk (i.e., calibration). However, evidence suggests there is a need to improve the methodological standards and increase consistency in the way CRPMs are developed and evaluated. In fact, although numerous caries risk assessment tools are available, most are not routinely used in practice or used to influence treatment decisions, and choice is not commonly based on high-quality evidence. Research will propose models that will become more complex, incorporating new factors with high prognostic value (e.g., human genetic markers, microbial biomarkers). Big data and predictive analytic methods will be part of the new approaches for the identification of promising predictors with the ability to monitor patients' risk in real time. Eventually, the implementation of validated, accurate CRPMs will have to follow a user-centered design respecting the patient-clinician dynamic, with no disruption to the clinical workflow, and needs to operate at low cost. The resulting predictive risk estimate needs to be presented to the patient in an understandable way so that it triggers behavior change and effectively informs health care decision making, to ultimately improve caries outcomes. However, research on these later aspects is largely missing and increasingly needed in dentistry.

Desensitizing Toothpastes for Dentin Hypersensitivity: A Network Meta-analysis

The goal of this systematic review and network meta-analysis was to compare the relative effects of toothpaste formulations for dentin hypersensitivity (DH), tested in randomized controlled trials (RCTs). We searched 7 databases to February 2019. Paired reviewers independently screened studies, extracted data, and performed risk of bias assessment. The outcome of interest was painful response measured through tactile, cold, and air stimuli. We conducted a random-effects Bayesian network meta-analysis using standardized mean difference (SMD) and their credible intervals (CIs) as the measure of effect for each pain stimuli. We assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included 125 RCTs (12,541 patients). For tactile stimulus, the following active ingredients showed large beneficial effects compared to fluoride with moderate certainty of evidence (SMD; 95% CI): potassium + stannous fluoride (SnF₂) (3.05; 1.69-4.41), calcium sodium phosphosilicate (CSP) (2.14; 0.75-3.53), SnF₂ (2.02; 1.06-2.99), potassium + hydroxyapatite (2.47; 0.3-4.64), strontium (1.43; 0.46-2.41), and potassium (1.23; 0.48-1.98). For cold stimulus, CSP showed large beneficial effects compared to fluoride (3.93; 0.34-7.53) with moderate certainty; for air stimulus, arginine (2.22; 1.45-2.99), potassium + hydroxyapatite (2.44; 0.33-4.55), potassium + SnF₂ (2.28; 0.87-3.69), CSP (1.98; 0.99-2.98), and SnF₂ (1.9; 1.03-2.77) showed large beneficial effects compared to fluoride with moderate to high certainty. Most toothpaste formulations showed evidence of superiority against placebo or fluorides (amine fluoride, sodium monofluorophosphate, or sodium fluoride). CSP was most beneficial for all 3 stimuli with high to moderate certainty. SnF₂ alone and potassium combined with SnF₂ or hydroxyapatite were beneficial for tactile and air stimulus with high to moderate certainty. Arginine was beneficial for air stimulus, and strontium and potassium were beneficial for tactile stimulus, with moderate certainty.

Social Media Research Strategy to Understand Clinician and Public Perception of Health Care Messages

Introduction:

Despite the potential of social media to influence public health and generate insights, the process of monitoring and analyzing the dissemination of health care messages on social media has been described as difficult and in need of improvement.

Objectives:

The objective of this study was to describe and demonstrate a reproducible methodology for cataloging and analyzing health care–related social media comments and provide insight into how clinicians and members of the general public respond to health care messaging on social media.

Methods:

We collected social media comments related to the American Dental Association’s 2016 “Evidence-Based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants” between April 10, 2017, and October 31, 2017, from Facebook, Twitter, LinkedIn, Reddit, and online message boards for the New York Times, FiveThirtyEight, and Dentaltown. Using data provided in the comments, we conducted engagement analysis as well as content, network, and sentiment analysis across 8 categories.

Results:

We collected 671 comments. Among our findings, Facebook (472 of 671) was the most popular platform among commentators; almost half of all comments (335 of 671) aligned with the recommendations of the 2016 American Dental Association sealants guideline; clinicians were more likely than the general public to like a comment that suggested an improvement to the guideline; and >75% of comments (521 of 671) were supported by anecdotal evidence.

Conclusion:

As the prevalence of anecdotes on social media suggests, the likelihood of falsehoods spreading on social media is high. Insights gleaned from the methodology described in this research could help combat the spread of such misinformation by providing disseminators of health care messaging with insight into their target audiences. Armed with this knowledge, disseminators can craft health care messages that more effectively engage clinicians and the general public.

Knowledge Transfer Statement:

The methodology used in this research provides a reproducible strategy for tracking social media engagement with health care messages. Engagement results can assist future delivery of health care messages to key stakeholders and ensure better implementation and adoption of these communications.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

Epidemiology of pediatric facial trauma in Chile: a retrospective study of 7,617 cases in 3 years

OBJECTIVES

To describe the epidemiology of facial trauma injuries in a group of Chilean children aged 15 years or less.

STUDY DESIGN

Retrospective study of case series. Between 2006 and 2009, clinical records of 293,090 patients were reviewed. Data of patients with trauma injuries to the face were collected and evaluated for: age, sex, day and month of hospital admission, cause of injury, anatomical location, type of injury and presence of associated injuries.

RESULTS

A total of 7,617 patients with 8,944 injuries were found. Boy to girl ratio was 1,7:1. Preschool age children were most frequently affected. Main cause of injury were falls, soft tissue injuries the most common type of injury. Associated injuries occurred in 11% of cases.

CONCLUSIONS

Facial trauma presents a significant frequency in the group of Chilean children studied. Preeschool age boys were prone to present facial trauma of mild severity associated to falls.

[Cross-sectional study of deviated nasal septum in unilaterally operated fissures]

INTRODUCTION

Nasal septum deviation is one the most significant nasal deformities among cleft and lip patients and its anatomical variations along the anterior-posterior axis within the nasal cavity has not been specified.

AIM

To define whether there are differences in the degree of nasal septum deviation between the anterior, middle and posterior areas of the nasal cavity in operated unilateral cleft lip and palate patients.

MATERIAL AND METHOD

Twenty-nine unilateral complete cleft lip and palate patients, between 5 and 17 years, attending San Borja Arriarán Hospital and the University of Chile's School of Dentistry were included. The nasal septum deviation index was measured at different depths across the anteroposterior axis by cone-beam computed tomography. A random effects model was performed for data analysis.

RESULTS

The nasal septum deviation index presented differences between the three planes studied. The plane with lesser deviation was the anterior, while the plane with greater deviation was the posterior. These differences resulted statistically significant (P < 0.05).

CONCLUSION

In complete unilateral cleft and lip patients mainly the posterior part of the nasal septum should be corrected, because there is a greater deviation in that area.

Determination of susceptibility to sensitization to dental materials in atopic and non-atopic patients

Introduction: Some studies report that atopic patients have a greater frequency of delayed-type sensitization than non-atopic patients. Objective: To determine the influence of the atopic condition on delayed sensitization to dental materials. Design: cross-sectional study. Methods: Forty (40) atopic subjects and forty (40) non-atopic subjects, of both sexes, between 20 and 65 years of age were included. The determination of delayed sensitization to dental materials was performed using patch test. An oral exam was also carried out to check for lesions of the oral mucosa. Results: 61.25% of the patients were positive for delayed-type sensitization to one or more allergens, being palladium chloride (21.25%), ammoniated mercury (20%), benzoyl peroxide (12.5%) and amalgam (10%) the most frequent. The frequency of sensitization was 67.5% in the group of atopic patients, compared to 55% in the non atopic group (p>0.05). The materials with the greatest difference of sensitization in atopic compared to non-atopic patients were ammoniated mercury, benzoyl peroxide, amalgam and Bisphenol A Dimethacrylate (BIS-GMA). Conclusion: The atopic condition is not related to a higher frequency of delayed sensitization to a battery of dental materials.

Key words: Patch test, delayed-type sensitization, allergy contact, atopia, dental materials.