Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania.

BACKGROUND: A panel convened by the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania conducted systematic reviews and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after simple and surgical tooth extraction(s) and for the temporary management (ie, definitive dental treatment not immediately available) of toothache associated with pulp and periapical diseases in adolescents, adults, and older adults. TYPES OF STUDIES REVIEWED: The panel conducted 4 systematic reviews to determine the effect of opioid and nonopioid analgesics, local anesthetics, corticosteroids, and topical anesthetics on acute dental pain. The panel used the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations, Assessment, Development and Evaluation Evidence-to-Decision Framework to formulate recommendations. RESULTS: The panel formulated recommendations and good practice statements using the best available evidence. There is a beneficial net balance favoring the use of nonopioid medications compared with opioid medications. In particular, nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications are first-line therapy for managing acute dental pain after tooth extraction(s) and the temporary management of toothache. The use of opioids should be reserved for clinical situations when the first-line therapy is insufficient to reduce pain or there is contraindication of nonsteroidal anti-inflammatory drugs. Clinicians should avoid the routine use of just-in-case prescribing of opioids and should exert extreme caution when prescribing opioids to adolescents and young adults.

Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania.

BACKGROUND: A guideline panel convened by the American Dental Association Council on Scientific Affairs, American Dental Association Science and Research Institute, University of Pittsburgh School of Dental Medicine, and Center for Integrative Global Oral Health at the University of Pennsylvania conducted a systematic review and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions and the temporary management of toothache (that is, when definitive dental treatment not immediately available) associated with pulp and furcation or periapical diseases in children (< 12 years). TYPES OF STUDIES REVIEWED: The authors conducted a systematic review to determine the effect of analgesics and corticosteroids in managing acute dental pain. They used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. RESULTS: The panel formulated 7 recommendations and 5 good practice statements across conditions. There is a small beneficial net balance favoring the use of nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen compared with not providing analgesic therapy. There is no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications, specifically nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen alone or in combination with acetaminophen, are recommended for managing acute dental pain after 1 or more tooth extractions (that is, simple and surgical) and the temporary management of toothache in children (conditional recommendation, very low certainty). According to the US Food and Drug Administration, the use of codeine and tramadol in children for managing acute pain is contraindicated.

Effect of CDC adjustment of state-reported data on community water fluoridation statistics.

OBJECTIVES: Advancing community water fluoridation (CWF) coverage is a national health objective. The Centers for Disease Control and Prevention began adjusting state-reported data to calculate CWF coverage in 2012, and then modified methods in 2016. We evaluate improvements attributable to data adjustment and implications for interpreting trends. METHODS: To assess adjustment, we compared the percentage deviation of state-reported data and data adjusted by both methods to the standard estimated by the U.S. Geological Survey. To assess effects on estimated CWF trends, we compared statistics calculated with data adjusted by each method. RESULTS: The 2016 method outperformed on all points of evaluation. The CWF national objective measure (percentage of community water system population receiving fluoridated water) was negligibly affected by method. Percentage of US population receiving fluoridated water was lower with the 2016 method versus the 2012. CONCLUSIONS: Adjustment of state-reported data improved overall quality of CWF coverage measures and had minimal impact on key measures.

Community Water Fluoridation Levels To Promote Effectiveness and Safety in Oral Health - United States, 2016-2021.

Drinking water fluoridated at the level recommended by the U.S. Public Health Service (USPHS) reduces dental caries (cavities) by approximately 25% in children and adults (1). USPHS recommends fluoride levels to achieve oral health benefits and minimize risks associated with excess fluoride exposure. To provide the benefits of community water fluoridation, water systems should target a level of 0.7 mg/L and maintain levels ≥0.6 mg/L (2). The Environmental Protection Agency (EPA) sets a safety standard at 2.0 mg/L to prevent mild or moderate dental fluorosis, a condition that causes changes in the appearance of tooth enamel caused by hypermineralization resulting from excess fluoride intake during tooth-forming years (i.e., before age 8 years). During 2016-2021, fluoride measurements for 16.3% of population-weighted monthly fluoride measurements (person-months) reported by community water systems to CDC's Water Fluoridation Reporting System (WFRS) were <0.6 mg/L; only 0.01% of person-months exceeded 2.0 mg/L. More than 80% of population-weighted fluoride measurements from community water systems reporting to WFRS were above 0.6 mg/L. Although 0.7 mg/L is the recommended optimal level, ≥0.6 mg/L is still effective for the prevention of caries. A total of 4,080 community water systems safely fluoridated water 99.99% of the time with levels below the secondary safety standard of 2.0 mg/L. Water systems are encouraged to work with their state programs to report their fluoride data into WFRS and meet USPHS recommendations to provide the full benefit of fluoridation for caries prevention.

Preventive Dental Care and Oral Health of Children and Adolescents With and Without Heart Conditions - United States, 2016-2019.

Approximately 900,000 U.S. children have heart conditions, such as congenital heart disease (1). These children might be at increased risk for life-threatening infective endocarditis from oral bacteria in the bloodstream (2). Therefore, preventive dental care (i.e., check-ups, dental cleaning, radiographs, fluoride treatment, or sealant) to maintain oral health is important. Oral health status and receipt of preventive dental care were compared between children with heart conditions (2,928) and without (116,826) using population-based 2016-2019 National Survey of Children's Health (NSCH) data. Approximately 83% of children with and 80% without heart conditions received preventive dental care in the past year (p = 0.06). Children with heart conditions were more likely than were those without to have poor oral health (17.2% versus 13.7%; p = 0.02) and teeth in fair or poor condition (9.9% versus 5.3%; p<0.01). Among those with a heart condition, having low household income; an intellectual or developmental disability; and no well-child visit or medical home were associated with poor oral health. Receipt of preventive dental care was higher among children aged ≥6 years and those with insurance. Public health practitioners and health care providers can implement strategies (e.g., parent and patient education and collaboration between pediatricians, dentists, and cardiologists) to improve oral health and care among children with heart conditions, especially those with fewer resources and intellectual or developmental disabilities.

Leaf Thermal and Chemical Properties as Natural Drivers of Plant Flammability of Native and Exotic Tree Species of the Valparaíso Region, Chile.

Forest fires are one of the main environmental threats in Chile. Fires in this Mediterranean climate region frequently affect native forests and exotic plantations, including in several cases urban and rural settlements. Considering the scarcity of information regarding the fire response dynamics of tree species that are frequently affected by fires, this study aims to establish a flammability classification according to the evolution of the fire initiation risk presented by the most affected forest species in the Valparaíso region. Three exotic species, Eucalyptus globulus, Pinus radiata, and Acacia dealbata, and two native species, Cryptocarya alba and Quillaja saponaria, were studied. Flammability assays indicate that E. globulus, A. dealbata, and C. alba are extremely flammable, whereas P. radiata and Q. saponaria are flammable. Furthermore, E. globulus and A. dealbata have the highest heating values while Q. saponaria has the lowest values. The extreme flammability of E. globulus, A. dealbata, and C. alba indicates a high susceptibility to ignite. Furthermore, the high heat of combustion of E. globulus and A. dealbata can be associated with a high energy release, increasing the risk of fires spreading. In contrast, Q. saponaria has the lowest predisposition to ignite and capacity to release heat. Accordingly, this work shows that all studied tree species contain organic metabolites that are potentially flammable (sesquiterpenes, aliphatic hydrocarbons, alcohol esters, ketones, diterpenes, and triterpenes) and can be considered as drivers of flammability in vegetation. Finally, these preliminary results will aid in the construction of more resilient landscapes in the near future.

The Impact of Dental Insurance and Medical Insurance on Dental Care Utilization During Pregnancy.

OBJECTIVE: To measure the association between dental and medical insurance with the receipt of dental cleaning during pregnancy. METHODS: We analyzed Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2015 on 145,051 women with a recent live birth from 36 states. We used adjusted prevalence ratios [aPR] from multivariable regression to examine the association of dental and medical insurance with receipt of dental cleaning during pregnancy, controlling for selected covariates that influence dental care utilization. RESULTS: Seventy-seven percent (77%) of all women reported having dental insurance during pregnancy. Receipt of dental cleaning before pregnancy was strongly associated with dental cleaning during pregnancy. Among women without pre-pregnancy dental cleaning who had dental insurance, those with Medicaid medical insurance had a significantly higher prevalence of dental cleaning during pregnancy [aPR = 1.42, 95% CI (1.32 - 1.52)], compared to those private medical insurance. Among women without pre-pregnancy dental cleaning, those without dental insurance but with Medicaid medical insurance were about 70% less likely to have dental cleaning during pregnancy compared to those with dental and private medical insurance. CONCLUSIONS FOR PRACTICE: With or without dental insurance, pre-pregnancy dental cleaning was strongly associated with dental cleaning during pregnancy. Dental insurance was an important determinant of dental utilization. Medical insurance had an independent and positive effect. This effect varied by private versus Medicaid medical insurance. Programs which provide women with dental insurance both before and during pregnancy could improve the oral health of maternal and infant populations.

Syngas Production From the Reforming of Typical Biogas Compositions in an Inert Porous Media Reactor.

Syngas production by inert porous media combustion of rich biogas-air mixtures was studied experimentally, focusing on carbon dioxide utilization and process efficiency. Different gas mixtures of natural gas and carbon dioxide, which simulated a typical biogas composition of 100:0, 70:30, 55:45, and 40:60 (CH4:CO2), were comparatively analyzed considering combustion waves temperatures and velocities, and chemical concentrations products, at high equivalence ratios of φ = 1.5 and φ = 2.0. Different CO2 concentrations on biogas composition showed higher H2 productions than on pure methane (100:0), mainly due to CO2 reforming reactions. Also, syngas production, hydrogen yields, and process efficiency by means of biogas filtration combustion were higher than under methane filtration combustion. Results of the thermochemical conversion of biogas show an alternative and promising non-catalytic technique to CO2 utilization.

Filled dietary fluoride supplement prescriptions for Medicaid-enrolled children living in states with high and low water fluoridation coverage.

BACKGROUND: Although dietary fluoride (F) supplements (DFS) are recommended for children who use F-deficient drinking water, no studies have examined filled DFS prescriptions across multiple states to examine the dosage consistency with current recommendations or prescription length. METHODS: This sequential cross-sectional analysis used Medicaid claims data for children aged 0.5 through 16 years who in 2011 lived in the 6 states with the lowest and the highest fluoridation coverage (≤ 34% and ≥ 95% of the public water system population fluoridated, respectively). For 2011, the authors calculated the mean percentage of children with filled DFS prescriptions and the change since 2000 across states with high and low fluoridation coverage, the percentage of children with filled DFS prescriptions containing F dosage consistent with current recommendations, and filled DFS prescription length and cost across states. RESULTS: In states with high fluoridation coverage, the mean percentage of children with a filled prescription was < 1% in both years; in states with low fluoridation coverage, this value increased from 0.9% to 10.3%, the highest increase (16.4 percentage points) since 2000 among children aged 0.5 through 2 years. The average prescription length was 72 days. Across states, the mean costs per child prescribed supplements and per enrollee were $17.60 and $1.05, respectively. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Filled prescriptions largely followed current recommendations but reached only a small percentage of children in low-coverage states. The short prescription length indicated limited exposure for caries prevention. Results from these states suggest more children could have longer exposure to the caries-preventive benefits of F at a similar cost with water fluoridation as with DFS.

Awareness Among US Adults of Dental Sealants for Caries Prevention.

INTRODUCTION: Dental sealants applied in childhood can help prevent caries, but knowledge of the availability of sealants and their function is not widespread. We assessed knowledge of dental sealants among US adults and adult parents of children younger than 18 and the differences in knowledge among demographic and socioeconomic groups. METHODS: We used data on 3,550 respondents to the 2015 FallStyles B survey of noninstitutionalized US adults aged 18 or older. Authors constructed estimates by using weights provided to reflect the distribution of the US population. Knowledge of dental sealants was assessed by sex, age, race/ethnicity, education, household income, and parental status. Multivariate analysis was conducted by using a main effects logistic regression model. RESULTS: Overall, 46.3% of adults and 55.1% of parents of children younger than 18 had knowledge of dental sealants. Sealant knowledge was highest among parents, women, respondents aged 45 to 59, and respondents with incomes greater than 200% of the federal poverty level and more than a high school education. Non-Hispanic blacks had less than half the odds of non-Hispanic whites of having knowledge of sealants (adjusted odds ratio [OR] = 0.4), and nonparents had half the odds as parents (OR = 0.5) of knowing. The strongest predictors of parental sealant knowledge were race/ethnicity, sex, and income. CONCLUSION: Disparities in sealant knowledge correspond to disparities in sealant prevalence. Increasing knowledge among low-income and racial/ethnic minority parents could reduce disparities in sealant prevalence and untreated caries.

Use of Toothpaste and Toothbrushing Patterns Among Children and Adolescents - United States, 2013-2016.

Fluoride use is one of the main factors responsible for the decline in prevalence and severity of dental caries and cavities (tooth decay) in the United States (1). Brushing children's teeth is recommended when the first tooth erupts, as early as 6 months, and the first dental visit should occur no later than age 1 year (2-4). However, ingestion of too much fluoride while teeth are developing can result in visibly detectable changes in enamel structure such as discoloration and pitting (dental fluorosis) (1). Therefore, CDC recommends that children begin using fluoride toothpaste at age 2 years. Children aged <3 years should use a smear the size of a rice grain, and children aged >3 years should use no more than a pea-sized amount (0.25 g) until age 6 years, by which time the swallowing reflex has developed sufficiently to prevent inadvertent ingestion. Questions on toothbrushing practices and toothpaste use among children and adolescents were included in the questionnaire component of the National Health and Nutrition Examination Survey (NHANES) for the first time beginning in the 2013-2014 cycle. This study estimates patterns of toothbrushing and toothpaste use among children and adolescents by analyzing parents' or caregivers' responses to questions about when the child started to brush teeth, age the child started to use toothpaste, frequency of toothbrushing each day, and amount of toothpaste currently used or used at time of survey. Analysis of 2013-2016 data found that >38% of children aged 3-6 years used more toothpaste than that recommended by CDC and other professional organizations. In addition, nearly 80% of children aged 3-15 years started brushing later than recommended. Parents and caregivers can play a role in ensuring that children are brushing often enough and using the recommended amount of toothpaste.

Vital Signs: Dental Sealant Use and Untreated Tooth Decay Among U.S. School-Aged Children.

BACKGROUND: Tooth decay is one of the greatest unmet treatment needs among children. Pain and suffering associated with untreated dental disease can lead to problems with eating, speaking, and learning. School-based dental sealant programs (SBSP) deliver a highly effective intervention to prevent tooth decay in children who might not receive regular dental care. SBSPs benefits exceed their costs when they target children at high risk for tooth decay. METHODS: CDC used data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 to estimate current prevalences of sealant use and untreated tooth decay among low-income (≤185% of federal poverty level) and higher-income children aged 6-11 years and compared these estimates with 1999-2004 NHANES data. The mean number of decayed and filled first molars (DFFM) was estimated for children with and without sealants. Averted tooth decay resulting from increasing sealant use prevalence was also estimated. All reported differences are significant at p<0.05. RESULTS: From 1999-2004 to 2011-2014, among low- and higher-income children, sealant use prevalence increased by 16.2 and 8.8 percentage points to 38.7% and 47.8%, respectively. Among low-income children aged 7-11 years, the mean DFFM was almost three times higher among children without sealants (0.82) than among children with sealants. Approximately 6.5 million low-income children could potentially benefit from the delivery of sealants through SBSP. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: The prevalence of dental sealant use has increased; however, most children have not received sealants. Increasing sealant use prevalence could substantially reduce untreated decay, associated problems, and dental treatment costs.

Durable Viral Suppression and Transmission Risk Potential Among Persons With Diagnosed HIV Infection: United States, 2012-2013.

BACKGROUND: We examined durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among human immunodeficiency virus (HIV)-diagnosed persons in care. METHODS: Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013. RESULTS: Of 265 264 persons in HIV care in 2011, 238 641 had at least 2 VLs in 2012-2013. The median number of VLs per individual during the 2-year period was 5. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years, 7261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year period) above 200, 1500, and 10 000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential. CONCLUSIONS: Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression.

Patterns and Trends of Newly Diagnosed HIV Infections Among Adults and Adolescents in Correctional and Noncorrectional Facilities, United States, 2008-2011.

OBJECTIVES: We aimed to determine whether the patterns and trends of HIV infections newly diagnosed within correctional and noncorrectional facilities differ. METHODS: We classified persons newly diagnosed with HIV infection in the United States between 2008 and 2011 (n = 181,710) by correctional and noncorrectional facilities where diagnoses were first made, and stratified by sex, age group, race/ethnicity, transmission category, and diagnosis year. RESULTS: An estimated 9187 persons were newly diagnosed with HIV infection in 2008 to 2011 while incarcerated, representing approximately 5.1% of the 181,710 HIV infections diagnosed in the United States during this period. Of these incarcerated persons, 84% were male, 30% were aged 30 to 39 years, 59% were Black/African American, and 51% of the men had been exposed through male-to-male sexual contact. Yearly numbers of diagnoses declined by 9.9% in correctional versus 0.3% in noncorrectional facilities. The percentage with a late HIV diagnosis was significantly lower in correctional than in noncorrectional facilities (prevalence ratio = 0.52; 95% confidence interval = 0.49, 0.55). CONCLUSIONS: Initial HIV diagnosis occurred sooner after HIV infection onset in correctional than in noncorrectional settings, pointing to the need for efficient referral systems after release.

Late Diagnosis of HIV Infection in Metropolitan Areas of the United States and Puerto Rico.

The majority of persons infected with HIV live in large metropolitan areas and many such areas have implemented intensified HIV testing programs. A national indicator of HIV testing outcomes is late diagnosis of HIV infection (stage 3, AIDS). Based on National HIV Surveillance System data, 23.3 % of persons with HIV diagnosed in 2012 had a late diagnosis in large MSAs, 26.3 % in smaller MSAs, and 29.6 % in non-metropolitan areas. In the 105 large MSAs, the percentage diagnosed late ranged from 13.2 to 47.4 %. During 2003-2012, the percentage diagnosed late decreased in large MSAs (32.2-23.3 %), with significant decreases in 41 of 105 MSAs overall and among men who have sex with men. Sustained testing efforts may help to continue the decreasing trend in late-stage HIV diagnosis and provide opportunities for early care and treatment and potential reduction in HIV transmission.

Care and viral suppression during the last year of life among persons with HIV who died in 2012, 18 US jurisdictions.

Death due to HIV remains a leading cause of death among some US populations, yet little is known about HIV care before death. We used data from the National HIV Surveillance System to determine disease stage and care within 12 months prior to death among persons infected with HIV who died in 2012. Persons were considered to be in care within 12 months before death if they had ≥1 CD4 or viral load test results, and in continuous care if they had ≥2 CD4 or viral load test results at least 3 months apart. Viral suppression (viral load <200 copies/mL) was based on the most recent viral load test result in the 12 months before death. Among 7348 persons infected with HIV who died in 2012, 47.1% had late stage disease (AIDS) within 12 months before death. Overall, 85.7% had ≥1 test result, 64.3% had ≥2 tests at least 3 months apart, and 41.6% had a suppressed viral load. While blacks and Hispanics/Latinos had higher percentages of continuous care compared with whites, they had lower percentages of viral suppression and higher percentages with late stage disease. Viral suppression was higher among older persons. The majority had been diagnosed with HIV more than 5 years before death (86.3%). Although the majority of persons infected with HIV who died in 2012 had been diagnosed many years before death, almost half had late stage disease, and there were disparities in late stage disease and viral suppression by race/ethnicity and age.