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.

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.

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.

Noninvasive assessment of diffusion hypoxia following administration of nitrous oxide-oxygen.

The phenomenon of diffusion hypoxia is commonly believed to occur unless nitrous oxide-oxygen inhalation sedation is followed by "washout" with 100% oxygen for 5 minutes upon termination of the flow of nitrous oxide. When systematically studied, however, this phenomenon generally appears to be unfounded. The present study evaluated the effect of breathing room air instead of 100% oxygen in healthy (ASA 1) human volunteers following administration of sedative concentrations of nitrous oxide. The occurrence of hypoxia was determined objectively, using pulse oximetry and a standardized psychomotor skills test (Trieger test). Diffusion hypoxia was not observed using these criteria.

Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment.

BACKGROUND: There is a widespread belief among dental practitioners and physicians that oral anticoagulation therapy in which patients receive drugs such as warfarin sodium must be discontinued before dental treatment to prevent serious hemorrhagic complications, especially during and after surgical procedures. OVERVIEW: The authors examine the scientific basis for properly managing the dosage of anticoagulants for dental patients who are receiving anticoagulation therapy. The authors review the appropriate laboratory test values to which dentists should refer when evaluating for dental treatment patients who are receiving anticoagulation therapy. The authors also review clinical studies, published within the past five years, that focus on the frequency and degree of hemorrhagic and related complications among dental patients who are receiving anticoagulation therapy orally to prevent thromboembolic events. CONCLUSIONS AND CLINICAL IMPLICATIONS: The scientific literature does not support routine discontinuation of oral anticoagulation therapy for dental patients. Use of warfarin sodium as it relates to dental or oral surgical procedures has been well-studied. Some dental studies of antiplatelet therapy are consistent with the findings in warfarin sodium studies. Dental therapy for patients with medical conditions requiring anticoagulation or antiplatelet therapy must provide for potential excess bleeding. Routine discontinuation of these drugs before dental care, however, can place these patients at unnecessary medical risk. The coagulation status--based on the International Normalized Ratio--of patients who are taking these medications must be evaluated before invasive dental procedures are performed. Any changes in anticoagulant therapy must be undertaken in collaboration with the patient's prescribing physician.

Avoiding complications in local anesthesia induction: anatomical considerations.

BACKGROUND: Dentists administer thousands of local anesthetic injections every day with few reports of serious complications. However, misjudging the anatomy involved during local anesthetic administration can result not only in inadequate or incomplete anesthesia, but in other complications such as paresthesia, bleeding or hematoma formation, or in serious systemic complications. OVERVIEW: The authors discuss anatomical considerations that dentists should keep in mind when administering local anesthetic injections. In particular, they discuss ways in which dentists can minimize the risk of nerve or vascular injury, as well as systemic complications. CONCLUSIONS AND CLINICAL IMPLICATIONS: Even the most experienced practitioner can benefit from a periodic review of the anatomy associated with local anesthesia. This article offers dentists the opportunity to consider needle placement with regard to location of nerves, blood vessels and glands, and to review injection protocols that can minimize the risk of complications.

The key to profound local anesthesia: neuroanatomy.

BACKGROUND: To achieve profound dental local anesthesia, it is necessary for the dentist to have a thorough knowledge of the details of sensory innervation to the maxilla and mandible. Since the early 1970s, dentistry has experienced a resurgence of interest in the neuroanatomical basis of local anesthesia, resulting in numerous scientific reports on the subject. OVERVIEW: Current studies afford a more detailed knowledge of the branching of various divisions of the trigeminal nerve, the great sensory nerve of the head region. In this article, the authors provide an update of the peripheral distribution of the trigeminal nerve to enhance induction of safe and effective dental local anesthesia. CONCLUSIONS AND PRACTICAL IMPLICATIONS: An understanding of the potential variations in innervation should help the dentist improve his or her ability to induce profound local anesthesia.

Local anesthetics: special considerations in endodontics.

Local anesthetics are essential for successful endodontic treatment, and their pharmacologic characteristics have special implications for the treatment of painful, chronically-inflamed or necrotic teeth. Their dosages must be limited to prevent toxicity, which may be enhanced by the coadministration of sedative agents or drugs which affect hepatic drug metabolism. Endodontic patients with established central and peripheral sensitization represent special challenges for pain control, since morphogenetic changes resulting from neurogenic inflammation can render pain fibers more resistant to local anesthesia. The use of vasconstrictors with conventional and alternative injection techniques, e.g., intraosseous injections, are necessary to prolong the duration of action of local anesthesia but can place patients with cardiovascular disease at some risk. An appreciation of all of these aspects of local anesthesia in endodontics will better prepare the operator for predictably safe and effective patient care.