A retrospective review of the use of oxymorphone immediate release for long term pain control in cancer patients with gastrostomy tubes.

BACKGROUND: Cancer patients often require feeding or venting gastrostomy-tubes (G-tubes) for enteral nutrition or symptom palliation. The administration of most extended-release (ER) opioids via the G-tube or orally followed by clamping of the venting G-tube is contraindicated. Oxymorphone immediate release (IR) may be useful because of its longer half-life compared to other IR opioids. We examined the use of oxymorphone IR administered every 8 hours in patients with G-tubes. METHODS: This was a retrospective chart review of 40 consecutive cancer patients with G-tubes who underwent opioid rotation (OR) to oxymorphone. Demographics, symptoms, morphine equivalent daily dose (MEDD), and oxymorphone dose were collected. Successful OR was defined as a 2-point or 30% reduction in pain score and continued use of oxymorphone at follow-up in outpatient setting, or discharge in inpatient setting. Opioid rotation ration (ORR) between MEDD and oxymorphone in patients with successful OR was calculated as MEDD before the OR divided by total oxymorphone dose/day at follow-up or discharge. RESULTS: The median age was 56 years, 57.5% were white, 68% male, 47.5% (n=19) had head and neck cancer, 90% had advanced disease, 67.5% (n=27) were inpatient, and 15% (n=6) had venting G-tubes. 25/40 (62.5%) patients had successful OR to oxymorphone. The median ORR from MEDD to oxymorphone was 3.5 (IQR, 3.1-4). There were no independent predictors for successful OR, and ORR did not significantly differ among various groups. CONCLUSIONS: Oxymorphone IR can be used successfully in cancer patients with G-tubes using an ORR of 3.5 to calculate dose from MEDD.

The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients.

BACKGROUND: Transdermal fentanyl (TDF) is 1 of the most common opioids prescribed to patients with cancer. However, the accurate opioid rotation ratio (ORR) from other opioids to TDF is unknown, and various currently used methods result in wide variation of the ORR. The objective of this study was to determine the ORR of the oral morphine equivalent daily dose (MEDD) to the TDF dose when correcting for the MEDD of breakthrough opioids (the net MEDD) in cancer outpatients. METHODS: The records of 6790 consecutive patients were reviewed at the authors' supportive care center from 2010 to 2013 to identify those who underwent rotation from other opioids to TDF. Data regarding Edmonton Symptom Assessment Scale scores and MEDDs were collected for patients who returned for a follow-up visit within 5 weeks. Linear regression analysis was used to estimate the ORR between the TDF dose and the net MEDD (the MEDD before opioid rotation [OR] minus the MEDD of the breakthrough opioid used along with TDF after OR). RESULTS: In total, 129 patients underwent OR from other opioids to TDF. The mean patient age was 56 years, 59% were men, and 88% had advanced cancer. Uncontrolled pain (80%) was the most frequent reason for OR. In 101 patients who underwent OR and had no worsening of pain at follow-up, the median ORR from net MEDD to TDF (in mg per day) was 0.01 (range, -0.02 to 0.04), and the correlation coefficient of the TDF dose to the net MEDD was 0.77 (P < .0001). The ORR was not significantly impacted by body mass index or serum albumin. The ORR of 0.01 suggests that an MEDD of 100 mg is equivalent to 1 mg TDF daily or approximately 40 micrograms per hour of TDF (1000 micrograms/24 hours). CONCLUSIONS: The median ORR from MEDD to TDF in mg per day was 0.01. These results warrant further studies.

Decision Making in the Treatment of Patients With Rheumatoid Arthritis and Periodontitis: Scientific Evidence and Clinical Experience.

Focused Clinical Question: What are the key considerations for coordination of care for a patient with rheumatoid arthritis (RA) and chronic periodontitis (CP), and what are the clinical implications of RA on periodontal health? Summary: Both RA and CP involve hyper-immune response and osseous destruction. However, despite emerging evidence that RA and CP may have common etiologies and patients with RA have increased risk of CP, periodontal evaluation and treatment remain largely similar for patients with and without RA. More fully assessing inflammatory burden in patients with RA and CP may allow practitioners to more accurately assess the risk profile of a patient for RA and periodontal disease progression and to better evaluate adequate end points to periodontal therapy. Furthermore, coordination of care for patients with RA and CP with their rheumatologist or treating physician could allow for advanced screening and prophylactic care that may prevent disease development or progression. Conclusion: For patients with RA and CP, evaluation of their rheumatoid disease activity score and periodontal inflamed surface area score, rather than traditional periodontal clinical measurements, along with additional biologic sampling methods may be appropriate measures to more accurately assess inflammatory burden in these susceptible patients.

Does Adjunctive Use of Growth Factors Improve Clinical Outcomes of Soft Tissue Grafting at Miller Class III Recession Defects? A Review of Current Evidence.

Focused Clinical Question In patients with gingival recession that is classified as Miller Class III, does adjunctive use of local growth factors with gingival grafting procedures improve clinical outcomes? Clinical Scenario A 31-year-old female presents with a chief complaint of gingival recession (GR) at teeth #4 to #13 (Fig. 1). Interproximal bone loss coronal to the level of the buccal GR is present. She is concerned about esthetics and would like to maximize her chance for complete root coverage. Her medical history is non-contributory, and she has no contraindications to routine dental care. Because of the number of teeth involved and the difficulty in harvesting autogenous tissues, she is treated with acellular dermal matrix§ and enamel matrix derivative‖ with a coronally advanced flap at teeth #4 to #13 (Figs. 2 and 3). Final results reveal significant root coverage on all teeth and complete root coverage on teeth #7 to #10. This results in an esthetically acceptable result (Fig. 4).

Healing Time for Final Restorative Therapy After Surgical Crown Lengthening Procedures: A Review of Related Evidence.

Focused Clinical Question In healthy patients who receive surgical crown lengthening, how much healing time should be allowed for the positional changes of the gingival margin before final restoration? Clinical Scenario A 59-year-old woman presented to the University of Alabama at Birmingham School of Dentistry in August 2011 for replacement of her existing porcelain-fused-to-metal crowns on the maxillary anterior teeth for esthetic reasons. Clinical examination revealed a diagnosis of developmental mucogingival deformity manifested by gingival excess in the maxillary anterior sextant. An esthetic evaluation was performed and identified excessive gingival display attributable to short clinical crowns and excluded vertical maxillary excess and short or hypermobile upper lip as etiologic factors. After signing a written informed consent, the patient underwent an esthetic crown lengthening procedure to correct this mucogingival deformity, followed by prosthodontic rehabilitation. The patient and restoring dentist were concerned with the healing time that should elapse before the teeth were permanently restored. Figures 1 through 5 illustrate the initial presentation of the patient, surgical crown lengthening procedure, and final restorations.

Does Non-Surgical Periodontal Therapy in Overweight and Obesity Result in a Change in Body Mass Index? A Review of Current Evidence.

Focused Clinical Question In patients with chronic periodontitis (CP) classified as overweight or obese who receive non-surgical periodontal therapy, is a change in body mass index (BMI) associated with periodontal treatment? Clinical Scenario A 47-year-old male presents to your office with a chief complaint of "I was told I have periodontal disease." He is missing tooth #9 and has significant supragingival and subgingival calculus deposits (Fig. 1). After examination, you assign a diagnosis of generalized moderate to severe CP. His probing depths (PDs) range from 2 to 8 mm, and his clinical attachment levels range from 2 to 8 mm, with 56% of sites demonstrating PD ≥4 mm. His medical history is significant for hypertension, osteoarthritis, gastroesophageal reflux disease, and obesity, with a current BMI of 31 kg/m2. He reports taking 5 mg enalapril every day, ibuprofen as needed for pain, and 20 mg omeprazole every day. Your treatment plan includes non-surgical therapy and periodontal reevaluation before possible phase II surgical treatment. The patient states that he recently read an article in lay media discussing the link between obesity and periodontal disease and is interested in optimizing his health.

Does Ridge Preservation at the Time of Tooth Extraction Improve Soft Tissue Volume and/or Implant Esthetics? A Review of Current Evidence.

Focused Clinical Question In patients with a hopeless tooth who receive dental implant therapy for tooth replacement, does extraction socket bone grafting, ridge preservation, or socket conversion at the time of tooth extraction result in improved gingival contours and/or peri-implant esthetics? Clinical Scenario A 54-year-old male presents for extraction of a restoratively hopeless tooth #10 (Figs. 1 and 2). He is systemically healthy and has no contraindications to routine dental care. He is interested in tooth replacement with an implant and has high esthetic demands. He asks whether there is a treatment sequence that will improve the quality and/or quantity of gingiva at the future implant site. After explanation, he opts for a delayed treatment approach with extraction and ridge preservation at tooth site #10 (Fig. 3). After initial healing, the local volume of keratinized gingiva at the site of future implant placement was adequate and the patient was satisfied with the final implant esthetic outcome after two years in function (Figs. 4 and 5).

Is Laser Disinfection an Effective Adjunctive Treatment to Bone Augmentation for Peri-Implantitis? A Review of Current Evidence.

Focused Clinical Question: In patients with endosseous dental implants that demonstrate peri-implantitis, does surgical bone augmentation with adjunctive laser implant surface disinfection have an effect on implant survival rates, and do these rates differ based on laser treatment modality? Clinical Scenario: A 55-year-old female presents 10 years after implant placement at sites #18 and #20 (Fig. 1). She demonstrates a 9-mm probing depth mesially and distally at implant #20. Bleeding on probing is present at all six sites around implant #20. The patient has not noted any discomfort, and suppuration has not been noted on clinical examination. Her medical history is significant for osteoarthritis, gastroesophageal reflux disease, and anxiety. She reports taking ibuprofen as needed for pain, 150 mg ranitidine twice daily, and 20 mg citalopram daily. The patient is concerned about the possibility of implant loss and states that she wants to save and treat the implant, if possible. During flap reflection, a circumferential defect at implant #20 is noted intrasurgically (Fig. 2).

Intravenous Bisphosphonates for Osteoporosis and Implant Placement.

Focused Clinical Question In a patient receiving intravenous infusion of nitrogen containing bisphosphonates for management of osteoporosis, is surgical implant treatment contraindicated because of the risk of impaired bony wound healing and osteonecrosis of the jaw? Clinical Scenario A 64-year-old postmenopausal woman who leads a busy life and works full time as a business executive presents with a fracture of her maxillary central incisors teeth #8 and #9. She has been a periodontal maintenance patient for the past 20 years with excellent oral hygiene. One month earlier, she experienced trauma to her anterior teeth by walking into a closed patio door. She appears younger than her stated age, and her overall health is good except for a history of postmenopausal osteoporosis diagnosed using a bone mineral density evaluation with a T-score at lumbar spine of -2.6. Currently, her only medication is a yearly intravenous infusion of zoledronic acid, which she has received for the past 3 years. The reason for this visit is to inform her that the teeth have a hopeless prognosis based on the progressive symptoms and will need to be extracted, and to discuss treatment options, risks, benefits, and alternatives.

Host Modulation for Smokers Undergoing Periodontal Maintenance: A Review of Current Evidence.

Focused Clinical Question In patients presenting with generalized moderate to severe chronic periodontitis and continuing to smoke, does host modulation improve the maintenance of alveolar bone support and clinical attachment level? Clinical Scenario A 45-year-old woman with a 25-pack-year history of smoking presents for comprehensive periodontal therapy including four quadrants of regenerative surgery and is now receiving supportive care at 3-month intervals. Clinical examination reveals excellent oral hygiene, and the patient resists a referral for smoking cessation. The patient is anxious about the potential for tooth loss. See Figures 1 to 3 for clinical presentation.

Women who smoke crack and their family substance abuse problems.

Toward the goal of understanding African American women who smoke crack cocaine and the family context in which their drug use occurs, this descriptive investigation aimed to characterize the relationship between the participants' substance abuse problems and that of their family members. We used previously collected data from interviews of 208 women and examined whether participants' substance abuse would closely parallel that of their family members, particularly male family members. Indeed, participants' drug use was highly correlated with partners' substance use (X(2) = 12.6; p < or =.001), father's substance use (X(2) = 11.9; p < or =.001), brothers' drug use (X(2) = 6.2; p < or =.05), and uncles' alcohol and drug abuse (X(2)= 5.3; p <=.05). Among female family members, only aunts' drug and or alcohol abuse (X(2) = 5.3; p < or =.05) was significantly correlated with that of the participants. These findings clearly support the hypothesis that the participants' substance use patterns are significantly correlated with that of male family members.