Designing audit and feedback dashboards for dentists to monitor their opioid prescribing.

BACKGROUND AND OBJECTIVE: Prescription drug abuse is a major factor leading to drug overdose deaths in the US and dentists are one of the leading prescribers of opioid pain medication. Knowing that Audit & Feedback (A&F) dashboards are an effective tool and are used as quality improvement interventions, we aimed to develop such dashboards personalized for dental providers which could allow them to monitor their own opioid prescribing performance. METHODS: In this paper we report on the process for designing the A&F dashboards for dentists which were developed by using an iterative human-centered design process. The results obtained from each iteration were used to enrich the information needs analyses, provide function testing, and guide the design decisions of the next iteration. RESULTS: Engaging dentists in the development and refinement of the dashboards while using the think-aloud protocol for user-testing, provided rapid feedback and identified areas that were confusing and needed either a redesign or additional explanatory content. The final version of dashboards consisted of displaying necessary information through easy to interpret visualizations and interactive features. These included providing access to current national and organizational prescribing guidelines, displaying changes in individual prescribing behavior over time, comparing individual prescribing rate to peer group rate and target rate, displaying procedure specific prescribing, integrating patient reported post-operative dental pain experience and providing navigation and interpretation tips for users. The dashboards were easy to learn and understand for the dentists and were deemed as worth using often in dental practice. CONCLUSION: Our research was able to demonstrate the creation of useful and usable A&F dashboards using data from electronic dental records and patient surveys, for dentists to effectively monitor their opioid prescribing behavior. Efficacy of the dashboards will be tested in future work.

Provider-directed analgesia for dental pain.

INTRODUCTION: Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry. AREAS COVERED: This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain. EXPERT OPINION: Substantial evidence-based literature shows a combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) where a short-course opioid prescription is appropriate in select patients, for which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

Patterns of opioid use among Texas dental practitioners during the COVID-19 pandemic.

OBJECTIVE: The primary objective of this study is to assess factors that influence opioid prescribing by dentists and the role of these factors in the practice of dental pain control. DESIGN: A 25-question survey instrument was distributed to the study population for anonymous responses, covering dentist and practice demographics and opioid prescribing characteristics. SETTING: Private solo and group practice settings, including general practitioners and dental specialists. PARTICIPANTS: Potential participants included all active members of a large state dental professional association. MAIN OUTCOME MEASURES: They were practitioner and practice demographic traits, types of opioids prescribed, and statistical correlations. Outcome variables included practice type, practitioner gender, practice location, practice model, and years in practice. Categorical covariates were summarized statistically by frequencies and percentages, and continuous covariates were summarized by means, medians, ranges, and standard deviations. RESULTS: Strongest correlations with opioid prescribing included general practitioner (vs specialist) and male gender. The coronavirus disease 2019 pandemic was confirmed as having exerted a significant impact on opioid prescribing among the survey respondents. CONCLUSIONS: Further research is warranted to assess post-pandemic opioid prescribing patterns, and additional educational strategies regarding limitations of opioid prescriptions should be applied to general, rather than specialty, dental practitioners.

The American Dental Association's Center for Evidence-Based Dentistry: a critical resource for 21st century dental practice.

Through its website (http:// www.ada.org/prof/resources/ebd/index.asp), the American Dental Association's Center for Evidence-Based Dentistry offers dental health professionals access to systematic reviews of oral health-related research findings, as well as Clinical Recommendations, which summarize large bodies of scientific evidence in the form of practice recommendations, e.g., the use of professionally-applied topical fluoride and pit-and-fissure sealants. Another feature of the site of great practical importance to the practicing dentist is the Critical Summary, which is a concise review of an individual systematic review's methodology and findings, as well as the importance and context of the outcomes, and the strengths and weaknesses of the systematic review and its implications for dental practice.

Apical root resorption is associated with comprehensive orthodontic treatment but not clearly dependent on prior tooth characteristics or orthodontic techniques.

SYSTEMATIC REVIEW CONCLUSION: Increased incidence and severity of external apical root resorption (EARR) occurred in patients undergoing comprehensive orthodontic therapy, especially when therapy involved higher levels of force than those commonly used for orthodontic tooth movement. CRITICAL SUMMARY ASSESSMENT: Results from a high-quality systematic review of 11 randomized clinical trials (RCTs) suggests that EARR has a multifactorial etiology; is associated with comprehensive orthodontics; supports the clinical use of light forces, especially during intrusion of teeth; and requires higher-quality research. EVIDENCE QUALITY RATING: Limited.

Sumter S. Arnim, D.D.S., Ph.D.: Texas leader in evidence-based dentistry.

Many lessons can be learned from the career of Dr. Sumter Arnim, chief among them that we have a professional obligation to apply scientific knowledge to the practice of dentistry and to involve our patients in their dental care, and to share this translational knowledge with one's colleagues. Arnim's work was an honor not only for the University of Texas Dental Branch (now, The University of Texas School of Dentistry at Houston), but for every school and student with whom he interacted. Our profession is better for having had Sumter Arnim as one of its members, and he can be credited with having played a leadership role in what is now known as evidence-based dentistry in Texas, the United States, and beyond. One of the authors of this paper (JVJ) had the opportunity to be a student at the University of Texas Dental Branch during the time that Dr. Sumter Arnim was faculty member. Dr. Arnim was deservedly respected by his students and faculty colleagues alike, due in no small part to his dedication to dentistry. This dedication to the profession was well known, as Dr. Arnim had been accepted to Yale University Medical School, but soon after enrollment there, he elected to pursue a Ph.D. degree in Pathology, rather than M.D. Dr. Arnim constantly stressed the bacteriologic nature of dental disease and the value of prevention to his Dental Branch students, serving as Director of the Postgraduate School with great distinction. His steadfast belief in the biological basis of dentistry was manifest in his frequent admonition to the student body: "You can either be doctors or hardware merchants." Finally, it is ironic that in 2011, the American Dental Association has reiterated some of Arnim's career themes in its current publication on barriers to oral health in the United States, with primary messages that include, "Prevention is essential. A public health model based on the surgical intervention in disease that could have been prevented after that disease has occurred, is a poor model," and, "Treating the disease without educating the patient is a wasted opportunity."

The curse of discovery: pioneers of dental and medical anesthesia.

The current practice of dental local anesthesia remains founded upon drugs and techniques that were developed over 100 years ago. 2009 marks the 125th anniversary of the pioneering use of cocaine as a topical anesthetic and the introduction of nerve block injections in the oral cavity and facial region. Four famous clinicians are recognized in this article, each for their unique contributions to "modern" local anesthesia (Carl Köller, Sigmund Freud and William Halsted) and general anesthesia (Horace Wells), with the recognition of the adverse impact of drug dependence on their personal lives, which fortunately did not preclude their positively revolutionizing the practices of dentists and physicians and their patients every since.

Comparative efficacy of 2 topical anesthetics for the placement of orthodontic temporary anchorage devices.

This study compared the effectiveness of topical benzocaine 20% versus a combination of lidocaine, tetracaine, and phenylephrine in providing sufficient analgesia for the placement of orthodontic temporary anchorage devices (TADs). The 2 topical anesthetics were tested against each other bilaterally using a randomized, double-blind, crossover design. The agents were left in place for the amount of time prescribed by the manufacturer. The TAD was then placed, and each subject rated the degree of pain on a Heft-Parker visual analogue scale. A pulse oximeter was used to record the preoperative and postoperative pulse rates. Statistically significant differences in perceived pain (P < .05) and success rate (P < .01) between drugs were seen, but no significant difference in pulse rate change between the topical anesthetics was observed (P > .05). It was concluded that when the efficacy of topical benzocaine and of a combination product was compared as the sole anesthetic to facilitate acceptable pain control for placement of orthodontic temporary anchorage devices, the combination product was considerably more efficacious.

HIV: medical milestones and clinical challenges.

Since its discovery in the 1980s, HIV has infected every continent on the globe by crossing socioeconomic, racial, ethnic, and gender barriers, and it continues to contribute to human morbidity and mortality. Advances in medicine and technology have led to new combination medications for HIV-positive patients, early HIV testing methodologies, and potential for an HIV vaccine, and they have given researchers and clinicians a larger armamentarium with which to treat and prevent the disease. Even with these vast improvements in HIV prevention, detection, and treatment, scientists have been unsuccessful in developing its vaccine. Therefore, the search for a cure for HIV remains the marathon of the millennium.

The Texas Dental Association and advocacy: a TDA president's perspective.

The TDA can take pride in the joint efforts of its leadership, its grassroots members, and its elected representatives in the middle of the decade of the 1990's. When asked about his legacy for the leadership of our organization, Dr. Eggleston emphatically states, "You have to act. You have to do the right thing even when you have critics and detractors." More recently, during his campaign for ADA President-elect, he constantly stressed the importance of our relationship with each other. Our relationship, in Dr. Eggleston's words now and during his TDA presidency, "is more important than all issues put together". As this brief retrospective illustrates, the issues faced by dentists and the TDA are never trivial and are always tied to the legislative process. Political advocacy by our association is, therefore, our first priority now, no less so than it was in the mid-1990's. As described in the recent "TDA Report Card" on our legislative agenda for the 80th Texas Legislature, our challenges continue unabated, but these challenges are answered, and in many cases, successfully overcome as a result of our advocacy efforts. Our need for constant involvement in the legislative process is perhaps best summarized by advice given to Dr. Eggleston by Senator (and oral surgeon) David Sibley at the 1995 TDA Annual Session. Senator Sibley complimented TDA on its achievements during the 1995 Texas legislative session, and added "but you've got to keep your garden weeded."

Migraine drug therapy: dental implications.

Triptan drugs continue to constitute the major pharmacotherapeutic interventional agents for migraine therapy. Interactions of dental drugs with migraine medications are limited, but their seriousness dictates that dentists be aware of the use of ergot alkaloids, triptans, or other migraine drugs. While many migraine sufferers avoid dental therapy dur ing migraine attacks, the practitioner who is treating a patient who has taken migraine medications must carefully monitor the cardiovascular status of the patient, which may affect the use of vasoconstrictors. Macrolide antibiotics and azole antifungals represent additional drug groups that are prescribed by dentists but which may potentiate the adverse effects of migraine drugs. Migraine patients prefer agents that offer rapid onset of relief and total relief within a couple hours of drug administration; they also prefer therapy that prevents recurrences and does not require "rescue" medications, and, of course, a lack of adverse effects and interactions with other medications. Currently, no single drug or class of drugs offers this ideal combination of actions in all patients.

Selection of local anesthetics in dentistry: clinical impression versus scientific assessment.

Since its introduction to in the United States about six years ago, 4% articaine with 1:200,000 epinephrine has been used by dentists as a local anesthetic agent. This article reviews three claims that have been advanced regarding articaine: high diffusibility, reduced incidence of failure in block injections, and effectiveness in achieving anesthesia when used in cases involving irreversible pulpitis.

Prescription opioid abuse: dental perspectives.

Drug abuse and diversion of controlled substances prescribed by dentists will continue to be an important issue in the overall management of dental pain, and must be recognized by the dentist. If suggested guidelines, regulations, and laws are observed, the associated problems for the dentist and the entire dental team and their patients can be minimized. Pain control is an essential service and duty for dentists, and the appropriate selection and use of analgesics affords this service with the best safety and efficacy.

Drug therapy for smoking cessation: evidence-based considerations for dentistry.

Meta analyses and systematic reviews reported to date provide substantial scientific support for certain forms of pharmacotherapy in smoking cessation. Less information is available on pharmacotherapy for intervention in other forms of tobacco abuse (i.e., spit tobacco). Prior to recommendation or prescription of nicotine replacements and/or prescription of bupropion, the dentist must recognize that drug therapy alone is not appropriate to assist patients in smoking cessation. However, when combined with appropriate behavioral interventions and a demonstrated willingness of the patient to quit tobacco use, drug therapy is a valuable adjunctive service.