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.

Dental therapy in the United States: Are developments at the state level a reason for optimism or a cause for concern?

Access to dental care continues to be a challenge for millions of vulnerable Americans. In more than 50 nations worldwide, dental therapists (DTs), mid-level providers who deliver a limited scope of dental care under the supervision of a dentist, have helped increase access to needed care. Since 2003, when the Alaska Native Tribal Health System introduced DTs as part of the Federally authorized Alaska Community Health Aide Program, a total of 13 states have adopted the role. However, as of April 2020, there are fewer than 150 DTs in practice throughout the country, and educational and licensing requirements as well as scope of practice vary between each state. Such heterogeneity makes the training and recruitment of future DTs a challenge. This article summarizes the current state of the DT workforce in the United States and discusses the possible future of the profession as other states contemplate adopting the model in the face of ongoing oral health disparities.

How US dental schools can better prepare their students to perform operative procedures.

OBJECTIVE: The aim of this study was to characterize the curricular and supplemental resources used by dental students during their operative dentistry course, survey students' perception of each resource's "helpfulness," and assess students' perceptions of preparedness to perform operative dental procedures in clinical settings. METHODS: American Student Dental Association delegates at all accredited dental education programs in the United States were asked to forward an email to students enrolled at their respective institutions explaining the purpose of the study and asking them to fill out our survey. The response rate was calculated using the targeted enrollment data found in American Dental Education Association Official Guide to Dental Schools. RESULTS: A total of 715 qualified respondents completed our questionnaire for a response rate of 13.5%. 90% of students felt at least "moderately prepared" to perform operative procedures in the clinical environment. The 3 most common curricular resources provided to students were lecture slides (n = 707, 99%), live lectures (n = 664, 93%), and live faculty demonstrations (n = 547, 77%). YouTube was the most common supplemental resource utilized by students (n = 575, 80%). When asked to select which resources were the most helpful for their learning, 49% (270/547) selected live faculty demonstrations, 27% (153/575) selected YouTube videos, and 23% (155/664) selected lectures/lecture slides. CONCLUSION: To best meet the expectations of the current generation of dental students and to prevent early-stage dental learners from being influenced by clinical misinformation online, dental schools should consider adapting and producing more online, video-based learning resources for their curricula.

Oral health care in the 21st century: It is time for the integration of dental and medical education.

Major issues exist in the provision of oral health care in America, especially to underserved populations. Access to care, health disparities, an aging population with higher chronic disease burden, and rising healthcare costs continue to impact health outcomes for millions. The marginalization of oral health care, like that of behavioral health care, is a contributor. This perspective presents an idea whose time has come: putting the mouth back in the body. Several national reports stress the imperative to better integrate the practice of medicine and dentistry, including the first-ever Surgeon General's Report on Oral Health in 2000. A plan to lead a multifaceted integration of oral health into overall health is proposed. Leaders will come from new educational and practice models stressing teamwork, interprofessional education, innovative residency training programs and even dual degree options.

Clinical Productivity and Medicare Payments Among Female and Male Oral and Maxillofacial Surgeons.

PURPOSE: To characterize and compare clinical productivity and payments between female and male oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries in 2017. MATERIALS AND METHODS: This cross-sectional study was composed of Medicare Provider Utilization and Payment Data from 2017. Providers were included if they were labeled as maxillofacial surgeons. The primary outcome variable was Medicare payment. Secondary outcome variables included clinical productivity (number of charges), unique billing codes, mean payment per charge, and beneficiary hierarchical condition category. Descriptive statistics and pair-wise comparisons were computed at an α level of .05. RESULTS: The analysis cohort was composed of 737 distinct OMSs, of whom 58 were women. Although female surgeons recorded higher mean clinical productivity, total Medicare payments, and number of unique Healthcare Common Procedure Coding System billing codes relative to male surgeons in both the facility and office settings, the differences were not statistically different. Payment per charge did not differ significantly between genders in the office setting. In the facility setting, women were reimbursed $63.74 per charge whereas men were reimbursed $109.69 per charge (P < .02). Female OMSs treated more medically complex patients relative to male OMSs (P < .02). CONCLUSIONS: Clinical productivity and total Medicare payments were similar between genders in both the facility and office settings, disputing prior surveys that illustrated bias about the productivity and ability of female OMSs. Female OMSs earned, on average, less per submitted charge in facility settings, which may be due to differences in documentation. The reason for this difference warrants further study.

Gender Differences in Academic Productivity and Advancement Among Dental School Faculty.

Background: An equal number of women and men are now graduating from dental school, but women dentists have lower income and are less likely to achieve positions of leadership, including within dental academia. Materials and Methods: Demographic information and academic rank were obtained for all faculty at the eight dental schools who received the most funding from the National Institute of Dental and Craniofacial Research in 2017. Years since dental school graduation, total number of PubMed-indexed citations, first- and last-author publications, and H-index were determined for each faculty member. Gender differences in productivity and advancement were evaluated. Results: Of 702 faculty members, 36.5% were female; only 24.4% of full professors were women. Men had significantly higher numbers of publications (30.2 [95% confidence interval [CI, 28.6-39.5] vs. 20.4 [95% CI 16.3-24.6], p = 0.02) and higher H-index (8.2 [95% CI 7.1-9.1] vs. 4.7 [95% CI 3.9-5.5], p < 0.0001). Women had graduated more recently than their male colleagues at all levels of academic advancement (overall 22.83 years [95% CI 21.29-24.39] vs. 30.19 years [95% CI 28.84-31.55], p < 0.0001). When corrected for academic productivity and years since graduation, the association between gender and academic rank was not significant. Conclusions: Women are underrepresented at each academic rank except instructor; however, women may advance more quickly than their male counterparts. Increasing scholarship and mentorship opportunities for female faculty members may help improve gender equity in dental academia.

Surgical Landmarks to Locating the Main Trunk of the Facial Nerve in Parotid Surgery: A Systematic Review.

PURPOSE: The purpose of this study was to describe distances from commonly used anatomic landmarks to the main trunk of the facial nerve during parotid surgery. MATERIALS AND METHODS: A systematic search of the published literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies from January 1, 1990 to January 1, 2017 that measured distances to the main trunk of the facial nerve from common anatomic landmarks were eligible. Inclusion criteria were English-language articles with distances measured from the main trunk of the facial nerve to anatomic landmarks. The primary outcome variable was the distance from the respective anatomic landmarks. Other variables included surgical approach, year, and existential status of subject (cadaveric or living). RESULTS: The search yielded 1,412 studies (1,397 by PubMed, 15 by reference searching), with 10 studies meeting the inclusion criteria. Within the 10 studies, there were 30 reported means and 375 dissected cadavers. The most common incision was the standard preauricular incision; the mean distances to the facial trunk from landmarks were 13.6 ± 11.0 mm (n = 6 reported means) for the tragal pointer, 8.79 ± 3.99 mm (n = 7 reported means) for the posterior belly of the digastric muscle, 10.5 ± 1.4 mm (n = 4 reported means) for the tip of the mastoid process, 14.99 ± 1.68 mm (n = 3 means) for the transverse process of C1, 3.79 ± 2.92 mm (n = 6 means) for the tympanomastoid fissure, 9.80 ± 0 mm (n = 1 mean) for the styloid process, and 11.77 ± 1.42 mm (n = 3 means) for the external auditory meatus. Formal assessment of inter-study variability could not be assessed because of the small number of studies and measurements. CONCLUSION: There are substantial variations in measurements from anatomic landmarks to the main trunk of the facial nerve in the literature. Therefore, multiple landmarks can be used to identify the main trunk of the facial nerve during parotid surgery. The distances reported in this study can guide surgeons during parotid surgery to decrease the risk of facial nerve damage.

Massachusetts Dental Schools Respond to the Prescription Opioid Crisis: A Statewide Collaboration.

The prescription opioid crisis has involved all sectors of U.S. society, affecting every community, socioeconomic group, and age group. While federal and state agencies are actively working to deal with the epidemic, medical and dental providers have been tasked to increase their awareness of the issues and consider ways to safely prescribe opioids and, at the same time, effectively treat their patients' pain. The Commonwealth of Massachusetts, under the leadership of Governor Charles D. Baker and his administration, challenged the state's four medical schools and three dental schools to improve their curricula to prepare the next generation of clinicians to deal with this crisis in an evidence-based, effective, and sympathetic way. This Perspectives article outlines the national prescription opioid crisis, details its effects in Massachusetts, and describes the interdisciplinary collaboration among the Commonwealth, the three dental schools, the Massachusetts Dental Society, and a concerned student group. The article also describes the efforts each dental school is undertaking as well as an assessment of the challenges and limitations in implementing the initiative. The authors hope that the Massachusetts model will be a useful resource for dental schools in other states.

WITHDRAWN: Health Policy Research May Ensure the Future of Oral and Maxillofacial Surgery.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.joms.2017.03.056. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Should Dental Schools Train Dentists to Routinely Provide Limited Preventive Primary Medical Care? Two Viewpoints: Viewpoint 1: Dentists Should Be Trained to Routinely Provide Limited Preventive Primary Care and Viewpoint 2: Dentists Should Be Trained in Primary Care Medicine to Enable Comprehensive Patient Management Within Their Scope of Practice.

This Point/Counterpoint acknowledges the transformation of dental practice from a predominantly technically based profession with primary emphasis on restoration of the tooth and its supporting structures to that of a more medically based specialty focusing on the oral and maxillofacial complex. While both viewpoints accept the importance of this transformation, they differ on the ultimate desired outcome and how changes should be implemented during training of dentists as oral health professionals. Viewpoint 1 argues that, in response to a shortage of both primary care providers and access to affordable oral health care, dentists need to be able and willing to provide limited preventive primary care (LPPC), and dental educators should develop and implement training models to prepare them. Among changes proposed are consideration of three types of practitioners: oral physicians with sufficient training to provide LPPC; dentists with excellent technical proficiency but minimal medical and surgical training; and mid-level providers to provide simple restorative and uncomplicated surgical care. Viewpoint 2 argues that the objective of dentists' education in primary care medicine is to help them safely and effectively provide all aspects of oral health care, including appropriate preventive medical care, that already fall within their scope of knowledge and practice. Dental educators should encourage students to use this knowledge to take full ownership of non-tooth-related pathologic conditions of the oral and maxillofacial complex not currently managed in the dental setting, but encouraging graduates to expand into non-dental LPPC outside the recognized scope of practice will only further exacerbate fragmentation of care.

The Impact of Integrating Oral Health Education into a Medical Curriculum.

OBJECTIVE: The purpose of this study was to evaluate our pilot program incorporating oral health education into the medical curriculum by evaluating students' perspectives on the oral health curriculum. SUBJECTS AND METHODS: Two hundred second-year students were asked to fill in a presession survey online regarding their familiarity with basic oral health concepts and their comfort level with performing oral examinations, and a postsession survey on paper that repeated the presession questions and added questions on the effectiveness of the session. RESULTS: Of the 200 students, 164 (82%) participated in the surveys. The pre- and postsurvey results showed that the session helped students become more comfortable with performing oral examinations and recognizing risks for periodontal disease, with an increase from 40 (27%) to 119 (82%) and 51 (35%) to 124 (86%), respectively. CONCLUSION: In this study, the oral health education session contributed to an increase in student awareness and understanding of oral health. Considering the reported effectiveness of the interactive session on student comfort with performing a basic clinical examination, this model shows promise for further use in other institutions.

U.S. Dental School Deans' Views on the Value of Patient-Reported Outcome Measures in Dentistry.

There has historically been limited development and utilization of patient-reported outcome measures (PROMs) in clinical dentistry. However, in recent years PROMs have been recognized by other health care fields as valuable in the comprehensive assessment of patient outcomes. The aim of this study was to survey deans of U.S. dental schools to better understand their vision for the role of PROMs in the field of dentistry. A 13-question online survey was emailed to the deans of the 64 accredited U.S. dental schools at the time to gather their opinions about the value of patient-reported outcomes in dentistry. The survey consisted of questions in 12 domains such as treatment planning, perceived success/complications of surgery, identification/management of dental pain, psychological and oral function, and insurance payment/reimbursement. Of the 64 deans, 33 responses were received (51.5% response rate), but three surveys were excluded due to incomplete answers, resulting in a final response rate of 46.8%. All respondents reported there was value in utilization of PROMs for understanding a patient's satisfaction of a procedure, a patient's perceived success of dental surgery, identifying dental pain, and managing dental pain. However, there was disagreement among the respondents about utilization of PROMs for the purpose of determining insurance payment and/or reimbursement. Additional steps should be taken to develop clinically appropriate PROMs for dentistry and to determine the appropriate situations in which to use dental PROMs. This study suggests that PROMs should be incorporated into dental school curricula as they will likely play a role in future comprehensive treatment assessment.

A New Integrated Oral Health and Primary Care Education Program in the Dental Student Clinic.

OBJECTIVES: The purpose of the study was to describe the implementation of a new program incorporating primary care education into a predoctoral dental curriculum in the StudentTeaching Clinic at Harvard School of Dental Medicine (HSDM) using the primary care rotations for students in a dental setting as a platform for change in our approach to patient care. METHODS: A survey of perspectives on the need for primary care medicine in dental education was distributed to all the deans of Commission on Dental Accreditation (CODA)-accredited dental schools in the continental United States for a total of 65 eligible schools. RESULTS: Of the 27 responses from the dental school deans, a majority of dental schools already had interprofessional collaborative practices at their schools, with collaborations with physicians and nurse practitioners being most common. Ninety-six percent of responders were supportive of integrating oral health and primary care to improve patient care and regarded primary care training for dental students as a potential method of improving patient care in dental education. CONCLUSION: As patient care involves multidisciplinary and interprofessional environments with a wide array of health care providers, curricular directions for dental school should explore an education model that incorporates the concepts of primary care medicine.

Health Insurance Affects Head and Neck Cancer Treatment Patterns and Outcomes.

PURPOSE: The purpose of this study is to examine the effect of insurance coverage on stage of presentation, treatment, and survival of head and neck cancer (HNC). MATERIALS AND METHODS: A retrospective study was conducted using the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with HNC. The primary variable of interest was insurance analyzed as a dichotomous variable: Patients were considered uninsured if they were classified as "uninsured" by SEER, whereas patients were considered insured if they were defined by SEER as "any Medicaid," "insured," or "insured/no specifics." The outcomes of interest were cancer stage at presentation (M0 vs M1), receipt of definitive treatment, and HNC-specific mortality (HNCSM). Multivariable logistic regression modeled the association between insurance status and stage at presentation, as well as between insurance status and receipt of definitive treatment, whereas HNCSM was modeled using Fine and Gray competing risks. Sensitivity logistic regression analysis was used to determine whether observed interactions remained significant by insurance type (privately insured, Medicaid, and uninsured). RESULTS: Patients without medical insurance were more likely to present with metastatic cancer (adjusted odds ratio, 1.60; P < .001), were more likely to not receive definitive treatment (adjusted odds ratio, 1.64; P < .001), and had a higher risk of HNCSM (adjusted hazard ratio, 1.20; P = .002). Sensitivity analyses showed that when results were stratified by insurance type, significant interactions remained for uninsured patients and patients with Medicaid. CONCLUSIONS: Uninsured patients and patients with Medicaid are more likely to present with metastatic disease, are more likely to not be treated definitively, and are at a higher risk of HNCSM. The treatment gap between Medicaid and private insurance observed in this study should serve as an immediate policy target for health care reform.