Okay, good afternoon, everybody. Welcome to today's AOAAM webinar, Opioid Prescribing by Dentists and Oral Maxillofacial Surgeons by Dr. Thumidhar Kuja. My name is Julie Kmic and I'll be your moderator for this session. This is the last of our spring webinars on hot topics in the treatment of OUD and stimulant use disorders. I'd like to introduce our speaker for today. Dr. Kuja is a dentist, health services researcher, and clinical assistant professor in the Department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry. Dr. Kuja received her degree in dentistry from King Abdul Aziz University in Jeddah, Saudi Arabia. She completed a master's in public health and a PhD in health services research at the University of Pittsburgh Graduate School of Public Health. She then completed her postdoc training in the Division of General Internal Medicine at the University of Pittsburgh School of Medicine. Dr. Kuja's research focuses on areas of high importance in dental public health, including prescribing in dentistry and access to oral health services using secondary data and advanced statistical methods. Her work on opioid prescribing in dentistry has informed upcoming American Dental Association guidelines on acute dental pain management in dentistry and has collaborated on policy reports locally and internationally. Dr. Kuja is one of a few dentists nationally with an interdisciplinary background in oral health epidemiology and policy and trained in oral health services research. Dr. Kuja is supported by a K99R00 award from the National Institute of Dental and Craniofacial Research. In her project, she uses mixed methods to develop a provider-centered intervention to improve opioid and antibiotic prescribing in ED settings. So welcome, Dr. Kuja. Thank you, Dr. Kimmich. And I'll start sharing my slides. Okay, looks good. Thank you so much for the introduction. I'm really excited to be here today. I was excited to share dental oral health research with a huge variety of audience, not just dentists. So today I'm going to share some of our group's work in opioid prescribing by dentists and oral maxillofacial surgeons in the United States. So the Opioid Research Response Network is funded by SAMHSA. I have nothing to disclose, nor does Dr. Kimmig. These are the learning objectives that were shared with you. And for today's lecture, I'm going to start with a little bit of background, and then I'm going to talk about our research on trends and trajectories of opioid prescribing by dentists and oral surgeons, and then the consequences of these prescriptions. I'm going to go into some qualitative research on why do dentists prescribe opioids, briefly go over who else prescribes for dental pain, and then I'm going to end with some kind of tips and tricks on how to help patients with dental pain in non-dental settings, where I'm going to mention the American Dental Association guidelines that were recently published for prescribing for dental pain. So to start with, what causes dental pain? Now, I know dental pain, if you ever had dental pain, or if you've ever seen someone with dental pain, it can be really annoying, right? And very, sometimes very severe. But it can be a consequence of dental disease, things like dental caries or cavities, or it could also be a result of a dental procedure, like a filling or an extraction. And I'm showing this really nice graph here just to say that dental pain happens in the periphery, it's driven by inflammation through the prostaglandin pathway, and because it's driven by inflammation, research shows us that non-steroidal anti-inflammatory drugs, such as ibuprofen and acetaminophen, are effective in dental pain management. In fact, they are superior to opioids in managing dental pain with little to no concern of side effects, and almost no concern of adverse outcomes, like addiction, and overdose, and death, and such. Now, despite the strong evidence of the efficacy of NSAIDs, and I'm an internationally trained dentist, and a lot of international dentists will tell you that we don't prescribe opioids for dental pain. However, opioid prescribing is common in US dentistry. In fact, previous research has shown that dentists in the US prescribe opioids almost 37 times more than dentists in the UK, despite having same oral health of the population and dental care use. Not only are dentists prescribing opioids, they had been identified among top opioid prescribers. In fact, 30% of teens get their first opioid from a dentist, usually after wisdom tooth extraction. And that is concerning, given the strong evidence, or longitudinal evidence showing that when teenagers get a legitimate opioid prescription during their teen years, they're more likely to abuse opioids as adults. And a lot of these prescriptions are excessive. Our survey data shows that over 50% of opioids prescribed for extractions go unused, opening the door for diversion. And I've heard of many parents who have told me that when their teenager was scheduled for a wisdom tooth extraction, new friends emerged, and then those friends disappeared, as did the opioids from their pharmacy cabinets. So dentists are prescribing a lot of opioids, but some of these opioids are also over-prescribed if we look at the CDC recommendations for acute dental pain management. Data from a commercially insured population shows us that over 53% of opioids prescribed by dentists exceed the recommended day supply of three days. And if you look at it in morphine milligram equivalents, or MMEs, 30% exceed those recommendations. So we know that there's been a lot of efforts to decrease opioid prescribing in the context of the current opioid epidemic, but I wanted to focus on what has been done in dentistry. So we know in 2016, the CDC released their guidelines, and although they were for chronic pain management, there was a part that was specific to acute pain, such as that's a result of dental pain, and the recommendation was no more than three days supply. So many states have continuous education requirements on opioid prescribing and dental pain for, I mean, prescribing for dental pain, for licensure and relicensure. Many states and institutions have developed guidelines and requirements for opioid prescribing. So for example, Pennsylvania was one of the first to publish guidelines for opioid prescribing in dental practice in 2015. The American Dental Association, or ADA, released its first statement on opioids in 2016, and then updated it in 2018. So we had a lot of different guidelines from different places, and there's a lot of variation between them, although all of them would recommend NSAIDs as the first line of treatment for dental pain. So there was like a lot of unspecificity, I would say, regarding to opioid prescribing, where the recommendation would say, when opioids are needed, no more than seven days supply. And that kind of was a little bit vague because when are opioids needed? Like what dental procedures do require opioids? Are they all the same? And what does no more than seven days supply mean? Is it no more, you know, seven days supply of codeine or the more potent oxycodone? And it wasn't until February of this year that the ADA actually released their guidelines for acute dental pain management that kind of handled a lot of those specificities that we're gonna talk about later, but hopefully that will help dentists as we go forward in our opioid prescribing. So in the following slides, I'm gonna talk about our research where we looked at, you know, national trends and trajectories of opioid prescribing by dentists and oral surgeons. And for the next slides, we use the Acuvula Longitudinal Prescription Dataset, which this database contains over 92% of prescriptions dispensed in U.S. retail pharmacies, including all payers. So Medicare, Medicaid, third party, and includes cash payments for medications. So in this slide, we're looking at trends in opioid prescribing by general dentists and dental specialists. And a specialist would be someone like an endodontist, a prosthodontist, a periodontist, or a pediatric dentist. It does not include oral surgeons just because that's how we got the data. So this is prescribing from 2012 to 2019, and we identified over 87 million opioids prescribed by dentists and specialists. However, if you look at, so this y-axis looks at the number of prescriptions and the x-axis is the years. And over these eight years, we can see that there's been a decrease in opioid prescribing by dentists by almost 55%, with kind of like the accelerated decrease starting in 2016, which is when the CDC guidelines were released. And we see also a change in the type of opioid prescribed. So in the earlier years of the study, hydrocodone used to be the favorite opioid prescribed by dentists, making almost 75% of their prescribing. But you can see that it's decreased to only a little bit over a half of what dentists prescribe at the end of the study period. We see a decrease in oxycodone prescribing, but we also see an increase in codeine and tramadol prescribing. So then we got the data for oral surgeons from 2016 to 2019. And over these four years, there were almost 14 million opioids prescribed by oral surgeons. And similar to what we see in dentists, there has been a decrease in opioid prescribing. However, to a kind of a lesser extent, if you compare them to dentists. So from 2019 compared to 2016, there was a 20% decrease in opioid prescribing by oral surgeons. But if you look at the same time period in dentists, it's almost 40%. And also there's a change in the type of opioid prescribed where oral surgeons still favor hydrocodone as their favorite opioid, but we see a decrease in oxycodone and an increase in codeine and tramadol. Now the increase in codeine and tramadol is interesting, and it could be because they are less potent and they have less restrictions on prescribing. So for example, you can call them in. However, codeine and tramadol have a FDA black box warning against prescribing them in children and adults, which we need to pay attention to as we continue our opioid mitigation efforts. So for the oral surgeons, I also looked at variation by state. And as you can see, so the overall picture is that opioids are decreasing, but when we looked by states, we found that there's a lot of variation. So this is looking at changes from 2019 compared to 2016. And while some states or the greener ones have decreased their prescribing a lot, you can see that a lot of states that are in the darker red have actually increased their prescribing, which is an interesting finding. So the good news is overall opioid prescribing by dentists and oral surgeon has been decreasing, but we see this variation by geographical area, which made us kind of think of what is the variation? Is there a variation and what's driving this variation? And that's kind of important as we devote our resources in creating targeted interventions. So in this next study, we put both data from dentists and oral surgeons together from 2015 to 2018, and we wanted to see if there's this variation. So we used a statistical method called group-based trajectory modeling, which is a method that allows you to create trajectories or groups based on their trajectory of a specific outcome. And in our case, it was the proportion of prescriptions by a dentist or a surgeon in a year that were opioids. And the model identified eight groups. And so, first of all, we found this group, this 14%, so over the 199,000 providers included, there was this 14% of providers who were basically non-prescribers where opioids made less than 1% of their prescriptions in a year. Then we have these, sorry, this is taking a while, the second three groups, so the brown, the dark blue, and the purple, who made up for almost over 40% of the providers who were kind of low prescribers throughout the study period. Then there was this group of 7.9% of prescribers, the gray group, that decreased their opioid prescribing rapidly by almost 80% over the study period. The second two groups that had similar trends were the, made up about 28% of providers, the green group and the turquoise group, who were moderately high prescribers at the beginning of the study, and then they continued to decrease. But what we found most interesting was this small percentage of 3.5% of providers who were continuously high prescribers throughout the study period. And although they decreased their prescribing, you can see, like a little bit, even at the end of the study period, their opioid prescribing rates were higher than the baseline of all other groups. And as we looked at the characteristics within the available variables that we had, we found that as you go higher in these prescribers from non-prescribers to consistently high prescribers, we see a higher proportion of oral surgeons made up in the groups, more prescriptions coming from the South, more prescriptions that were high risk based on the CDC definitions of no more than three days supply and no more than 50 MMEs per day. So we thought we were interested in looking at these consistently high prescribers and seeing if there's any differences within that group. So we took that red group, the 3.5%, of about over 6,000 providers, and we looked at their trajectories separately. So what we found was there was four groups, and three of these groups, the gray, the blue, and the red, had kind of similar trends of not decreasing much despite being at different levels. But there was this one group, the orange group, of about 7.5% of providers who decreased their prescribing rapidly over the study period within this high prescribing group by almost 60%. And again, within the available variables that we had in our data, we found that comparing this group to the other groups, they were pretty much similar, except that at baseline, this orange group had more reimbursements from Medicaid. So we think it could be Medicaid's opioid prescribing policies that kind of pushed these providers to change their prescribing behavior. And there was less oral surgeons in this group compared to the other groups. And we know that procedures that are done by oral surgeons are usually thought of as more painful, like extractions and similar things. And within this data, we didn't have the exact procedure that was done for an opioid prescription, but the evidence supporting NSAIDs as the most effective for dental pain is based on the third molar arism tooth impaction model, which is kind of one of the most aggressive procedures that are done in oral surgery. And so we think that there are opportunities to improve prescribing for dental pain for oral surgical procedures. So indeed, we found variation in dentists' opioid prescribing where most dentists decreased their prescribing rates by anywhere from 30 to 80% in those groups that we saw. Then there was a small group of dentists that had the highest opioid prescribing rates and at baseline, it continued to prescribe at high rates. And within that high prescribing group, there was a small group that decreased their prescribing more rapidly. And so what we took from this study is that targeted interventions are needed and we need to devote our resources for those who are continuing to prescribe at high rates. And understanding the characteristics of these rapid decliners can help inform these targeted interventions to their peers who have not responded to the opioid sparing efforts so far. So our data went up to 2019 and I was interested in looking if there's any more recent data. And indeed, there was a study that used the exact same dataset and included data until 2022. So we included the COVID-19 period, which I think we all remember vividly, there was a disruption in healthcare services and oral healthcare services. And so similar to what we found up to 2019, there was a decrease in opioid prescribing by dentists and oral surgeons. And this decrease was about 4% per month. But in June of 2020, we see this increase in opioid prescribing by dentists. And although there was a decline after that, it was at lower rates than it was pre-pandemic. And what the authors conclude is that because of this increase, there have been six more million dental opioid prescriptions from June to December of June 2020 to December 22, than had if we had continued the previous trends. So the previous trends would have been this red dashed line, but because of this disruption, we have, you know, there's an increase, which, you know, we could be catching up after the opioid epidemic, but I think it's important for us to think about dental pain management and prescribing of opioids in, you know, such circumstances when oral health services are disrupted. So going to the next portion of what are the consequences of prescribing opioids in dentistry? And early on when it was, you know, when dentists were identified as among top prescribers, there was this argument of, well, you know, these are immediate release opioids, they're short acting, they're not really, you know, a concern like the long acting opioids. However, there had been research that immediate release opioids prescribed in non-dental settings, like for example, after birth, increased the risk of persistent opioid use, abuse and adverse outcomes. And some of the earlier studies that looked at persistent opioid use or the consequences within a dentistry looked at wisdom tooth extractions. So it was usually looking at adolescents and for example, this was one of the first studies that found that the risk of persistent opioid use was almost three times higher when patients got an opioid for wisdom tooth extraction, regardless of how complex the procedure was, meaning it was a simple extraction or more like a complex extraction. Another study among adolescents who are commercially insured found that those patients who got an opioid after wisdom tooth extraction had a 16 fold increase in opioid misuse and abuse in the following year. Another group found that persistent opioid use was three times higher when opioids were prescribed for dental procedures compared to if they were not. And the 90 day risk of overdose was almost one and a half time higher when patients filled versus did not fill an initial opioid for a dental procedure. So concerning consequences, however, what we found is that a lot of these studies kind of focused on certain dental procedures for certain age groups. So a lot of them look at wisdom tooth extraction and they don't include all dental procedures where we know that opioids are prescribed for all sorts of dental procedures and we don't know what the consequences are. Overprescribing has not been evaluated whether the opioid prescription is in recommendations or not. And little was done about serious adverse outcomes like hospitalization or ADUs for these short acting opioids. So in the next two studies, we wanted to look at opioid prescribing, including all dental procedures. So for this study, we looked at dental procedures among patients who are in Pennsylvania Medicaid. So the publicly insured low income populations from 2012 to 2017. And our main objective was to assess the risk of getting that initial opioid prescription following a dental procedure based on the likelihood of pain associated with the procedure. So we'd classified all dental procedures into mild, moderate, and high based on the likelihood of pain after that procedure. Our second objective was kind of like conditional on filling that initial opioid. What was the risk of persistent opioid use? And we looked at it in two definitions following what we saw in the literature. There was the short term definition about filling one or more prescription within four to 90 days post-procedure with the four days cutoff being based on the fact that post-procedural dental pain rarely exceeds three days. And then there was a long-term definition also of filling a prescription of opioid 91 to 365 days post that initial dental opioid and looking at their persistent opioid use. So we included patients 12 to 64 years old in Pennsylvania Medicaid who got a dental procedure and we only included opioid naive, meaning they didn't have an opioid prescription in the six months before their index dental procedure where they get their opioid. So we identified over a million dental procedures and here we're looking at the risk of getting an initial fill of an opioid. And kind of what we expected is that the more painful the procedure of like high pain, so for example, surgical extraction, the more likely a patient's gonna get an initial opioid and it decreases with procedures moderate pain and low pain. So low pain would be something like a simple filling, moderate pain would be something like a root canal. And in this slide, we're looking at the persistent opioid use. So at the left is the short-term definition and on the right is the long-term definition of persistent opioid use. And regardless of the level of pain of the procedure, getting an initial fill of opioid was associated with an increased risk of persistent opioid use compared to if a patient did not get an opioid for the initial at that visit. So that's comparing the blue bars to the green bars in both definitions. What we found more interesting is that the risk of persistent opioid use was highest when procedures were, when a patient got an opioid for a procedure that was perceived as low pain. So if you compare these blue bars together, you can see that the risk is highest when the procedure is for mild pain, which is concerning. Now, within the limitations of the data, what we thought about is it could be that, you know, a patient came to the dentist with pain, they needed like a root canal or an extraction, something more, you know, definitive and the dentist couldn't do it at the same day. And within the dental claims data, we don't have diagnosis codes, we only have procedure codes. So we know what was done, but we don't know why it was done. And so the dentist could have just given them an opioid to carry them until they get that final procedure done or the definitive dental care and the patient just, you know, didn't reschedule and they continued in pain. Or as we know, a lot of Medicaid patients find difficulty accessing dental care. And for example, in Pennsylvania, Medicaid doesn't cover root canals. So it could be that the patient just couldn't find a provider that would do that definitive, you know, care and they, you know, continued in pain. However, it's like of concern that the lower the pain, the higher the risk of getting persistent opioid use. In this slide, we just wanted to look descriptively at the changes in the risk of persistent opioid use following the Pennsylvania guidelines that were released in 2015 on prescribing in the dental practice. And we found across the levels of pain that the risk decreased of these persistent opioid use. And although this is very descriptive, it just kind of gives us indications that these policies or guidelines can have an impact on prescribing. So that was our first study in Pennsylvania Medicaid. And in this next study, we looked at not only persistent opioid use, but we also wanted to look at the more serious or some serious adverse outcomes that I'm gonna define in a second. And in commercially insured populations, and our main kind of variable of interest was whether the opioid was within the limitations of guidelines or was over prescribed. We also wanted to look at the changes in our outcomes before and after 2016, which is when the CDC guidelines were released. So we included adults with a dental visit and a same day opioid prescription from a national commercial claims data set from 2011 to 2018. We had two main outcomes of interests. The first is adverse outcomes, which was a composite measure of any emergency department visit, hospitalization, newly diagnosed substance use disorder, naloxone administration or death within 30 days from the dental opioid prescription, which we refer to as an index, the index. The second one was persistent opioid use, which we defined, we used the short term definition of a more than one opioid prescription 40 to 90 days post index. But we also looked in sensitivity analysis, looked at the other definitions of persistent opioid use. And our main independent variable was over prescribing, which was defined as more than 120 morphine milligram equivalents for the total prescription. And for reference, 120 MMEs would equal 12 hydrocodone 10 milligram tablets. So we identified over 600,000 dental visits. And of those, 2.6% developed an adverse outcome, which was mainly an AD visit. And 16.6, that our definition for persistent opioid use, now it's a short term definition. We also looked at it with longterm and that prevalence increased to 24%. Then we looked at another definition that recommended a opioid prescription in short term and an opioid prescription on longer term. And it kind of decreased the prevalence to 6%. But however, you look at it, which definition there is that risk of persistent opioid use after a dental opioid prescription. So these are main outcomes. And although we adjusted for a number of variables, I'm only sharing those that were both statistically and clinically significant. So when we look at our main independent variable of overprescribing, we found that the risk of adverse outcomes, there was a risk, but it was similar whether an opioid was overprescribed or within recommendations. However, the risk of persistent opioid use was higher when opioids exceeded recommendations. And kind of similar to what we found in Medicaid, the risk of both adverse outcomes and persistent opioid use was highest when a patient got an opioid for a procedure that was considered a mild pain. So if you look at this nice characterization of pain that I found on the internet, if you get an opioid for a level one procedure, so that would be something like a simple filling or a cleaning, your risk of adverse outcomes of persistent opioid use is higher than if you get it for like a really painful level five, I don't know how to say that, but procedure like a surgical tooth extraction. So we really need to be careful when prescribing for procedures with mild pain, they're all perceived with mild pain. We also found that the risk of these outcomes is highest when a patient had a prior SUD or substance use disorder diagnosis or had a prior emergency department visit, which indicates that dentists need to get thorough histories from their patients and be careful when prescribing opioids for these patients. In this slide, we're looking at our second objective or in the changes in outcomes pre and post 2016 when the CDC guidelines were released. And interestingly, we found an increase in adverse outcomes while we saw a decrease in persistent opioid use. I'm just gonna give you a second here to think about it, of like why these different findings and kind of think about what is the definition of both outcomes. So what we thought of is that persistent opioid use is a reflection of opioid prescribing, which we know nationally has been decreasing and kind of makes sense that persistent opioid use, that outcome has been decreasing. However, adverse outcomes, remember that includes hospitalization, Alexander administration and death at composite measure, that's a reflection of any opioid, including in its illicit forms, which we know has been increasing and it could be explanation of why adverse outcomes increased. So the main takeaway is that opioid prescribing by dentists, although it's immediate release opioids are associated with adverse outcomes and persistent opioid use. And we should be paying attention to reducing opioid prescribing for procedures that are low pain risk. We need more efforts to improve analgesic prescribing in the dental practice, especially in patients who have high risk of opioid related adverse outcomes like those with substance use disorders. And up to when we published these two papers, the guidelines by the ADA had not been published and these two papers had informed the recently published guidelines, which is exciting. And it's also good that the guidelines kind of took these things into consideration. So we talked about that dentists prescribe a lot of opioids, these opioids are over prescribed, opioids are over prescribed and there are consequences to that. But why do dentists prescribe opioids, right? And so in this study, our group conducted a qualitative kind of research where we interviewed over 72 dentists and oral surgeons from around the country from a practice-based research network. And we asked them about their opioid prescribing. And these are some of the themes that came up. So dentists knowledge of the opioid risk of the opioid epidemic or even being touched personally by the opioid epidemic like having a patient or a family member or a friend being impacted by the opioid epidemic has influenced them to decrease their prescribing. Some dentists actually even give up their DEA license and had policies that they're not prescribing opioids anymore. Dentists also mentioned that having state regulations like checking the prescription drug monitoring program or having limits on prescribing has helped them decrease their prescribing. Another important facilitator was the dentist's ability to communicate pain management plans with their patient. So kind of talking to the patient that some discomfort is expected, but it will go away within three days. If it doesn't go, then you have to come back. Thinking about other modalities of pain management like preemptive analgesia, so giving a patient an answer before they start a procedure and then giving them anesthesia before they leave the clinic and talking about other ways to help them manage pain, like for example, putting cold compressions after extraction. So kind of clear communication with the patient of what is expected and when to come back for follow-up or concerns with pain. And this interesting barrier that came up was a fear of negative consequences for saying no to opioids. So some dentists, especially those in rural areas, there could be only like two providers in the whole area. And the dentist was worried that if I stopped, if I say no to opioid prescribing, and then the patients might go to the other dentist who is prescribing opioids, and the word of mouth, like their kind of reviews would be impacted. Another interesting one was a dentist's ability to identify substance use disorder behavior. So a lot of dentists said they don't have any training in dental school to handle that, and they don't know how to manage patients with substance use disorder. And so that was one of the things that is an area of intervention. And this is just a quote that I highlighted talking about that. Another quote here that I'm gonna let you read at your own time, but it's also interesting because some dentists prescribing behavior changes based on the day of the week. So if it's Monday, then they're just gonna prescribe ibuprofen and acetaminophen. But if it's the end of the week, it's before the weekend, or if the dentist is going out of town, then they're more likely to prescribe an opioid, like just give them like a paper prescription to fill if they need it, like this just in case prescribing because they're worried that the patient would be in pain, and then who's gonna help the patient. So this was kind of an interesting part too of the just in case prescribing, which the guidelines have also recommended against. So all my work on prescribing for dental pain by dentists made me think about who else prescribes for dental pain. Now, we know that these dental pain that is caused by not trauma, basically non-traumatic dental conditions are very common. And a lot of patients for many reasons end up in the AD. So we think access to dental care difficulties and access to dental care, or if it's after hours or like the weekend and the patient has pain and can only be able to go to the AD. And it's pretty common. It's actually 10 times more common than visiting the AD for myocardial infarction. And for all these dental problems, the main treatment is getting a dental procedure done. So for example, a root canal or an extraction, something like that. But in the AD isn't the right setting for those procedures. And therefore what providers can do is only palliative care. And previous research showed that over 50% of patients who come to the AD with dental pain get an antibiotic and over 40% fill an opioid, regardless of clinical indication. And some of my preliminary work that I've done where I looked at AD visits for dental pain and the prescribing using electronic health record data with integrated with claims data, we found that the opioid prescribing in the emergency department for dental pain has been decreasing in the past years, but we see an increase in antibiotic prescribing. And so that's like the current project that I'm working on right now with my KN-NT9, where I'm looking at quantitative and qualitative methods to see how AD providers are managing dental pain. And then that information will help us create interventions in the emergency department. And hopefully we can extend it to other non-dental settings to help with prescribing for dental pain. So finally, how can we help our patients with dental pain in non-dental settings? So we said dental pain can be a result of dental disease or dental procedure. And dental disease or dental caries is one of the most common one of them. And it's a progressive disease. It can start being like in the outer layer of enamel where it doesn't hurt at all. And then it can progress and gets closer into the dentin and into the dental pulp where all the nerves are and becomes really painful. And then it can also lead to inflammation in the area surrounding the root. So that's a different kind of pain. And it also can extend to the bone, the alveolar bone, with an abscess where a real infection happens. And so these are just like some clinical pictures of like simple caries, more deep caries, and then an abscess here intraorally. And you can see this radiolucency in the radiograph. But regardless of what the cause is, the treatment is always definitive dental care. So we need to have that restoration done or filling or a root canal is needed where the pulp of the tooth is removed and cleaned and filled or an extraction depending on the situation. And these are the ADA guidelines that were recently published. And they have two set of guidelines. They have one for teenagers and adults. So starting from 12 years and above, and then they have another set for children. And I think the guidelines kind of emphasize patient communication. They included a patient group when they were developing the guidelines and put that into this consideration of when to prescribe. And so I'm gonna simplify this whole flow chart into one thing. Whatever the cause of the dental pain is, you always have to refer to dental care. So it's important to have resources for dental care. And regardless what the pain causes the pain, the first line treatment is always ibuprofen 400 milligrams or 440 milligrams of naproxen sodium with or without 500 milligrams of acetaminophen. What you can do in the clinic or in the visit to help the patient is like dental anesthesia, a nerve block or infiltration anesthesia using 2% lidocaine plus epi and or 0.5% of pubivacaine with epi kind of giving that immediate acting and more longer term acting. And again, this is just to help the patient go through that acute phase of the pain until they can get their definitive dental procedure done. The guidelines do have this condition of like if the patient can't get adequate pain control after the first line therapy, then they do recommend adding a combination opioid and just like changing the dosing of acetaminophen here to make sure that we don't go over the limit. But they do recommend adding a combination opioid at the lowest effective dose, fewest tablets and shortest duration which rarely exceeds three days supply. And to me personally, that was surprising that an opioid option was there given those strong evidence of NSAIDs and everywhere else in the world, nobody gets opioids for dental pain. However, the patient group's perspective was important in forming this. They wanna make sure that there is an option of opioids if they are in severe pain. So this is for children. And for children, it's again, less than 12 years old. And for children, it's NSAIDs and acetaminophen and no opioids are recommended for children. And also no anesthesia is recommended because there is a risk of lip injury or cheek injury when children are anesthetized. The dosing depends on the weight of the patient. And finally, I wanna just like go a little bit over antibiotics because they're also like common when we talk about dental pain. And this thought, do we need antibiotics for dental pain? Like if you see this kid here with all these bad teeth, do we need to prescribe an antibiotic? Well, the idea also has guidelines on that. And the short answer is antibiotics don't work for dental pain. There are only certain areas when, or certain conditions where there's an infection that in immunocompetent patients, antibiotics are recommended. So it's in cases where you have a visible abscess with or without systemic signs of infection. As long as you see that intraoral abscess then and without the, regardless if you have access to definitive dental care that needs, you prescribe an antibiotic. There's a case of delayed prescribing. Those are in cases when there is no visible abscess but the patient complains of pain when they're biting or chewing. And then if you tap the tooth, so there's some pain or tenderness on percussion or palpation, but the tooth is not responsive to cold stimulus. So basically it's a dead tooth or a necrotic tooth where the inflammation is spreading to the area around surrounding the roots of the tooth. So in those cases, you give a patient a delayed prescription of an antibiotic and tell them to call them if their condition is progressing where they start seeing that swelling or having systemic signs of infection. What you can do in the clinic is do an incision drainage of the abscess. And the recommended antibiotic is amoxicillin 500 milligrams three times a day for three to seven days. The guidelines also go into whether if a patient has a penicillin allergy or if first line treatment doesn't work, which I'm not gonna go through, but it's here for your reference and it's available in the guidelines. So that's been very helpful in guiding our prescribing of antibiotics. And finally, here I'm just summarizing all what we said about like what to do, how to diagnose a patient with dental pain. So in these conditions when the cavities are pretty small, superficial, usually a patient doesn't have any pain, isn't complaining of pain, there isn't much to do except tell the patient that they need to get the, see a dentist and get that looked at. When it gets deeper and closer in the dentin, the pulp starts to get inflamed, but the pain is only triggered by thermal changes, you're hot or cold and are eating sweets, so it's triggered. If you do a cold test, meaning you put a cold stimulus in the tooth and remove it, the pain kind of goes away immediately. It doesn't linger, it doesn't stay. What you can do is provide that first line analgesia and it's optional to provide dental anesthesia to that patient. Also tell them that they need to go see the dentist to get that done because it can progress. Now, these cases are the kind of most common emergencies or dental pain emergencies. So in this, if you can see here, the cavity is pretty big and it's really encroaching the pulp and it's kind of irreversibly inflamed. And this is when the patient has that spontaneous pain, it's very acute, it's exaggerated with thermal changes. Usually the patient can't tell you which tooth hurts, but they can tell you it's somewhere here. That's because the pain is coming from the pulp, which doesn't have any proper reception. And then there's usually no pain on biting or chewing. And if you do that cold test and if you remove the stimulus, the pain lingers. It really stays there. So what you can do during the visit is provide dental anesthesia and the first line therapy for dental pain and then tell the patient that they need to go urgently to see the dentist and that this can progress and they might, so kind of give them that option of follow-up. So when the inflammation goes around the tooth and then the periapical area becomes inflamed, the periodontal ligament that surrounds the root, that's when the patient starts getting pain on biting or chewing. And usually can't tell you which tooth it is because the periodontium has that proper reception. And with cold tests, it could be both ways. It could be lingering pain, like the patient, so it's still here in the vital stage or it can have no response. So the tooth is already dead, like necrotic and it won't have any response. It will be tender to palpation and percussion. And what we can do is give dental anesthesia, first-line treatment for analgesia. And in the case is when the tooth is not vital, but you feel that the pain has that pain and chewing and biting, and you don't see an abscess, you can give that delayed prescription and tell the patient to fill it if their symptoms get worse. And of course, always refer to dental care. Our final case is when the tooth is dead, it's necrotic and we have that abscess there. And it can be very painful also, and spontaneous pain and biting and chewing. And usually the patient can tell you which tooth it is. It's not responsive to cold because it's a dead tooth. It can be tender to palpation and percussion. What it can do is provide some anesthesia. And also, this is mentioned in the guideline by providing incision and drainage can also help the patient relieve that pain. Analgesia is the same thing. And this is the case when we prescribe an antibiotic with an urgent referral for definitive dental care and kind of telling the patient that they need to be followed up within three days because there's a concern of that deeper space infection. So that was my talk for today. Thank you so much for listening and I'm happy to answer any questions. Okay, thank you so much. That was really interesting data that you presented and this part at the end too about different dental caries and abscesses is really relevant to a lot of the work that we do in addiction. Because like you said, I think a lot of our patients don't get to dental care or have a hard time accessing dental care. And so a lot of times when I'm on our inpatient withdrawal management unit, I have dental complaints, and people requesting antibiotics quite a bit. So opening it up to any questions that anybody in our audience has. So please feel free to put your questions in the Q&A. Somebody had asked about bleeding risk pre and post procedure. Please address regarding that ibuprofen prescription. Sorry, what was the question? The question is about bleeding risk pre or post procedure. Yeah, with ibuprofen. Like in cases when ibuprofen is contraindicated. Yeah, the guidelines recommend going to the full dose of acetaminophen of 100,000 milligrams. Yeah, and that's not exceeding 4,000 in a day. And they also have that option of the combination opioids when it's, when ibuprofen is contraindicated. Okay, somebody had mentioned, thank you for an eye-opening and dynamic presentation. Okay, next we do have another question here. As an emergency physician, I'm frequently told patients can't get an appointment for months, can't see a specialist, or must travel long distances. Any efforts to make emergency dental care more accessible to rural and underserved area? Yeah, that's like the root cause of everything, right? Access to dental care. And it is very challenging, as you said, in rural areas and whatnot. And honestly, that is one of the things that we are thinking about of what works. I know that in some health systems, they have a general practice residency, for example, that can be useful where the dentist is in the hospital and can manage those patients. I know that's not available in every system. Teledentistry is becoming another area of becoming more popular where dentists can diagnose and can tell you what you can do at the moment. So I've been talking to ED providers around the country about how they manage dental pain. And some areas also have that arrangement with dental clinics around, close by, where especially like federal qualified health centers and whatnot that can take patients on a sliding scale, or some of them have like a 24-7 walking clinic. And those kinds of models are helpful. However, I know they're not available everywhere. And this access to dental care continues to be an ongoing challenge. And we really trying to work on how to improve that. Some places have, some states do have dental therapy that, I mean, has been seen to be helpful with access to dental care. But again, that's not available everywhere. But I agree, we need to, at the end of the day, you need to get the dental procedure done. And unless the patient gets that done, it's gonna be just a recurring problem. So yeah, need to think about how to make that more accessible. Yeah, and the person who asked the question also had mentioned that their dental clinics locally are overrun or very busy and can't put people in. Okay. We do have a question about antibiotic preference for patients with a penicillin allergy. Oh yeah, we can go back to these slides. So the guidelines do talk about whether it's a, oops, sorry, let me see if I can go back. Yes, if it's a true allergy, if it's not a true allergy. So, and they kind of talk about it, because they say a lot of patients say that they have an allergy, but it's not a real one. So if the patient doesn't have a history of anaphylaxis, angioedema, or hives with penicillin or amoxicillin, then the recommendation is cephalaxine. But if they do, then the first one is, the first recommendation is azithromycin. And they kind of put clindamycin as the second option and kind of caution, you know, providers against the risk of, is it called C. diff? Yeah, like the side effects of clindamycin, they're favoring azithromycin over it. Does that answer your question? I was just thinking back to one of those first slides with the map, and you had shown that some states increased their prescribing or had increased prescribing of opioids. And I was just wondering, you know, I remember like the highest was over in maybe like Wyoming or Montana. Yeah, and I was just wondering what you make of that. Yeah, we actually, within this data set, we didn't have much information, but we know that there's a lot of varying policies around the country with, you know, prescribing for opioids within dentistry and oral, I mean, this is oral surgery. So, you know, we don't really know what exactly is the driver. There are also differences in access to dental care that we didn't adjust for in this analysis, but we know that Medicaid doesn't cover dentistry. So it's not like they don't have to cover it for adults. They have to cover it for children, but they don't have to cover it for adults. And so states vary in what they cover and when they cover. So we could see a state that covers it a year and the next year their budget is constrained and then they cut dental because, you know, that's the easiest one to cut. And, you know, with the ACA, with the what's it called, the Affordable Care Act, with the expansion, there have been states that have included dental care. And, you know, those could be also areas of where, you know, that helps getting dental care and decreases the independence on opioids. So, yeah, it is an interesting question. And one of the reasons why we did this GPTM analysis, but within the data that we have, we didn't find much different, you know, variables that differed between those who increased and those who didn't increase, except those, what I mentioned with Medicaid reimbursement and how much of them are oral surgeons. But yeah, like in ongoing research, there's an interest to see, to kind of dig deeper into what, you know, drives that variation and whether the recent guidelines will, you know, help change that too. We have one, a comment question by one of our participants who's in Wisconsin and he mentioned that they developed a dental pain protocol for non-traumatic dental pain in the emergency department and urgent care and have expanded the training with their colleagues in the IHS nationally. And he's in discussion with the American College of Emergency Physicians to expand the trainings they've developed on a national basis. Oh, that's great. Thank you so much. Yes, I am interested and I will reach out to you. Thank you, Russell. Yeah, that's like, I just submitted actually an abstract to ACIP where we kind of are looking at the, you know, what we found talking to the providers and what they tell us and what they think works and what we, what our proposed interventions are. So yeah, this is, it is exciting because I do know that we all as healthcare providers wanna do what's best for our patients with like the balancing, the managing the pain versus all these problems of access to dental care. So it is a really tricky situation and I wish we could have a dentist for every, you know, person that needs it in time, but there's a lot of challenges with that too. And our, you know, emergency departments are kind of overwhelmed with seeing these conditions where they can't do much, right? So yeah, excited to talk more about it. Any other questions? Hi. Well, if no more questions, I wanted to thank you so much for sharing your experience and your research with us. This was a really excellent talk. We have a lot of comments here, feedback from the audience that they really enjoyed it and learned a lot. So thank you again so much for speaking for our group today. And I just wanted to remind everybody that this was our last webinar of our spring series, but we do have a summer series coming up in August. So watch your emails for our webinars then and sign up. Again, it's going to be six different webinars on opioid use disorder as well as stimulant use disorders. And then go and complete the survey on our education page where you registered for this webinar so you can get your CME credits. And if you haven't done that already for the other webinars, go back and do the evaluation so you can claim your CMEs for that as well. So thank you everybody for participating this spring and thank you to Nina and Judy for being around to help facilitate these webinars and everybody have a good summer.

Dr. Thumidhar Kuja

opioid prescribing practices

dentists

oral maxillofacial surgeons

United States

dental pain

access to dental care

rural areas

underserved areas