The Opioid Analgesic Reduction Study (OARS) Pilot: A Double-Blind Randomized Multicenter Trial.

BACKGROUND: With addiction rates and opioid deaths increasing, health care providers are obligated to help stem the opioid crisis. As limited studies examine the comparative effectiveness of fixed-dose combination nonopioid analgesia to opioid-containing analgesia, a comparative effectiveness study was planned and refined by conducting a pilot study. METHODS: The Opioid Analgesic Reduction Study (OARS) pilot, a stratified, randomized, multisite, double-blind clinical trial, was designed to test technology and procedures to be used in the full OARS trial. Participants engaged in the full protocol, enabling the collection of OARS outcome data. Eligible participants reporting to 1 of 5 sites for partial or full bony impacted mandibular third molar extraction were stratified by biologic sex and randomized to 1 of 2 treatment groups, OPIOID or NONOPIOID. OPIOID participants were provided 20 doses of hydrocodone 5 mg/acetaminophen 300 mg. NONOPIOID participants were provided 20 doses of ibuprofen 400 mg/acetaminophen 500 mg. OARS outcomes data, including pain experience, adverse effects, sleep quality, pain interference, overall satisfaction, and remaining opioid tablets available for diversion, were collected via surveys, electronic medication bottles, eDiary, and activity/sleep monitor. RESULTS: Fifty-three participants were randomized with 50 completing the OARS pilot protocol. Across all outcome pain domains, in all but 1 time period, NONOPIOID was better in managing pain than OPIOID (P < 0.05 level). Other outcomes suggest less pain interference, less adverse events, better sleep quality, better overall satisfaction, and fewer opioid-containing tablets available for diversion. DISCUSSION: Results suggest patients requiring impacted mandibular third molar extraction would benefit from fixed-dose combination nonopioid analgesia. KNOWLEDGE TRANSFER STATEMENT: Study results suggest fixed-dose nonopioid combination ibuprofen 400 mg/acetaminophen 500 mg is superior to opioid-containing analgesic (hydrocodone 5 mg/acetaminophen 500 mg). This knowledge should inform surgeons and patients in the selection of postsurgical analgesia.

Fat body protein granules and storage proteins in the silkmoth, Hyalophora cecropia.

Fat body cells of silkmoth pupae (Hyalophora cecropia ) contain granules, showing a less dense outer zone and a denser, often crystalline, inner portion appear after cocoon spinning and increase until the larval-pupal ecdysis; more granules are formed in females than in males. Urate granules, appearing fibrous in internal structure, first form about the same time, but their accumulation is more gradual, and continues in the pupa. Both types have been isolated by centrifugation. Protein granules dissolve in buffers to yield proteins 1 and 2, with distinct electrophoretic and antigenic properties. These proteins have been isolated individually from pupal fat body extracts by using their different thermal stabilities in phosphate buffer containing MgCl2 and (NH4)2SO4, respectively, and purification was completed by gel chromatography. Protein 1 has a molecular weight of 480,000 and a subunit of 85,000 daltons, while protein 2 gives values of 530,000 and 89,000, respectively. Their amino acid compositions are similar but distinct. Proteins 1 and 2 accumulate in the hemolymph, beginning 3 days before spinning, reach maximal levels at spinning, and then decline in the hemolymph while granules are formed in the fat body, although the total hemolymph protein concentration does not decline at this time. It is concluded that the fat body of the late, feeding larva synthesizes two related "storage proteins" and secretes them in partially crystalline granules as protein reserves for metamorphosis.

Burning mouth syndrome.

Complaint of a burning mouth is an increasingly common problem in the aging population. This has remained an enigma for the treating clinician, because visible pathologic lesions or processes are usually not evident. Local, systemic and environmental causes must be assessed to elicit the predisposing factors. Some suggestions for managing burning mouth syndrome are offered.

Transmission of infectious disease in the dental setting.

Patients in the industrialized world are at low risk of acquiring nosocomial infections; nevertheless, several aspects of care in the hospital or clinic can place patients at risk from infectious disease transmission. Paramount to the prevention of disease is the strict adherence to universal precautions for all patients. Tuberculosis has again emerged as a potential epidemic capable of dramatic morbidity and mortality. The World Health Organization estimated that 22.6 million people were infected with HIV and that 50 million would be infected by the year 2000. The main types of viral hepatitis are hepatitis A through G. The chance of transmitting hepatitis B virus is higher than the chance of transmitting HIV. As knowledge regarding the pathophysiology and transmission of these diseases has increased in recent years, some insight has also been gained into the problems related to transmission of diseases between individuals. This paper will discuss the transmission of tuberculosis, hepatitis and HIV as related to the dental setting and health-care workers.

Peripheral trigeminal nerve surgery for patients with atypical facial pain.

Atypical facial pain (AFP) is characterized by a constant, poorly defined anatomically aching pain, lacking the paroxysmal quality, trigger point activation, and well-defined anatomical distribution of trigeminal neuralgia. This study examines a set of AFP patients with respect to their responses to external decompression (4 patients) and neurectomy (11 patients). Criteria for trigeminal nerve exploration were: failure of non-operative treatments, the ability to control pain temporarily with local anesthetic nerve blocks, and pain generally located within the anatomical distribution of the affected nerve. Decision as whether to perform an external decompression or neurectomy was based on gross anatomical findings during exploration. A retrospective interview was conducted to evaluate the effects of the chosen procedure in regard to subjective level of pain, freedom from restrictions placed on activities of daily living, and past medical history, including history of the facial pain. The neurectomy procedure (p = 0.022), medical history of autoimmune disease (p = 0.004), and preoperative pain distribution on the left side (p = 0.042), were all found to have a positive effect on outcome. History of psychiatric treatment (p = 0.055) and preoperative affected activities of daily living (p = 0.026) significantly adversely affected the outcome.

Graft-versus-host disease. Case report and discussion.

The graft-versus-host disease reaction is an immunologic consequence resulting from the grafting of immunocompetent cells from one individual to an immunocompromised host. The oral manifestations of this disease process include severe oral pain, xerostemia, ulcerative lesions, and mucositis. With appropriate history and diagnostic testing, these lesions can be differentiated from other oral diseases having similar clinical appearance.

Intraoperatively fabricated bite block in the management of scar contracture hypomobility.

Intraoral surgical procedures produce scar tissue formation that may limit mandibular opening. Many procedures have been developed to release these scar contractures, but most lead to further scar formation and greater limitation in opening. The purpose of this article to describe a technique with the use of an intraoperatively fabricated self-curing acrylic bite block combined with aggressive physical therapy in the management of this difficult clinical problem.

Nuclear dacryoscintigraphy: its role in oral and maxillofacial surgery.

Obstruction of the lacrimal drainage apparatus may result in excessive tearing or epiphora. This may occur as a result of a traumatic injury or accumulation of debris, mucus, or pus. In nuclear dacryoscintigraphy, a radioactive solution is introduced into the conjunctival sac by pipette and allowed to follow the flow of the tear solution through the lacrimal drainage system. This article will review normal lacrimal anatomy and indications for nuclear dacryoscintigraphy in oral and maxillofacial surgery.

Differential diagnosis of jaw pain in the elderly.

While many diseases are marked by pain in the mandible or maxilla, a number of these conditions appear to be more prevalent in people 65 years and older. People in this age group often have a number of medical problems and take a variety of medications, so clear-cut diagnosis of jaw pain can be difficult. Memory deficits or concomitant somatic complaints can further complicate the diagnosis. This article presents a differential for jaw pain in the elderly and reports on a pertinent case.

Using fenestration technique to treat a large dentigerous cyst.

Dentigerous cysts are commonly encountered in the practice of dentistry and oral and maxillofacial surgery. Treatment modalities range from enucleation to marsupialization, and are based on the premise that the pathological process can be controlled locally with minimal injury to the adjacent host structures. In a child, however, loss of permanent tooth buds in the management of a large dentigerous cyst can be devastating. This article describes the technique of fenestration, which removes this entity and preserves the developing dentition.

Relationship of the infraorbital nerve and vessels in the pathogenesis of idiopathic trigeminal neuralgia: a theoretical discussion and cadaveric study.

Many etiologies have been postulated to explain the pathogenesis of Trigeminal Neuralgia (TN). Most theories focus on a demyelinating process resulting in ephaptic transmission and recruitment of small pain fibers or a restrictive relationship of the superior cerebellar arteries and the trigeminal nerve roots at the level of the pons which may lead to demyelination. It is postulated that vasodilation or constriction of these vessels in a confined bony canal can create localized regions of demyelination and restrictive relationships creating painful stimuli. It is the purpose of this study to grossly investigate the relationship of the infraorbital nerve and vessels passing through the infraorbital canal to discuss whether their relationship may play a role in the pathogenesis of idiopathic TN. Patterns of relationship have been elucidated and will be described. This preliminary gross anatomical study should set the framework from which to base further microscopic and clinical studies.

Management of condylar fractures in children: review of the literature and case presentations.

The treatment of mandibular condylar fractures has remained a controversial subject. Although many fractures can be treated by closed reduction with subsequent physiotherapy, others are treated by open reduction and rigid internal fixation. The management of these fractures in children and adolescents is more controversial. This article will review the treatment options for condylar fractures in children along with indications and contraindications for open repair.

Adjunctive cervicofacial liposuction.

Submental liposuction is an adjunctive surgical procedure that allows for the relatively predictable soft tissue recontouring of the cervicofacial region (Figs. 13 to 17). It may be performed independently as an outpatient procedure under intravenous sedation or as an adjunctive procedure during orthognathic surgery. Surgical complications are rare and are usually preventable with appropriate patient selection and surgical technique. Submental liposuction is a useful tool for enhancing the esthetic benefits of orthognathic surgery.

Mechanisms of trigeminal nerve injuries.

Injuries to the trigeminal nerve branches are a known and accepted risk in oral and maxillofacial surgery. It is prudent for the practitioner to explain the risks to patients as part of the informed consent process and to recognize and document the presence of nerve injury postoperatively. Patients should be referred to a surgeon experienced in microsurgical techniques in a timely fashion for evaluation and possible surgical intervention if an injury is not resolving.

Guided tissue regeneration in dentistry.

Guided tissue regeneration (GTR) is a technique currently used in dentistry for periodontal surgery, oral surgery, implant dentistry and reconstruction of maxillomandibular defects. The basic premise for this technique is to allow for osseous regeneration prior to soft tissue migration into the area of interest. This is accomplished with the use of membranes that prevent the migration of the soft tissue element into the bony defect. This paper discusses current uses for GTR techniques and reviews some of the materials now available for this purpose.

Management of sickle cell/beta thalassemia patient with severe odontogenic infection.

The sickle cell diseases are caused by a genetic mutation in the hemoglobin molecule, resulting in the decreased ability to transport oxygen with subsequent clinical ramifications secondary to the sickling of the red blood cells. Routine dental and oral surgical management is possible in the office with adherence to basic principles, including hydration, oxygenation and adequate anesthesia/analgesia. The underlying pathophysiology and management protocols for the sickle diseases are discussed.

Trigeminal nerve injuries.

Injuries to peripheral branches of the trigeminal nerve are relatively uncommon; however, they are fairly debilitating to the patient when they do occur. Treating clinicians should evaluate and document baseline neurosensory testing results on patients and perform serial examinations approximately every two weeks. If there are no changes after one month, consideration should be given for referral to an oral and maxillofacial surgeon trained in trigeminal nerve microsurgery. Many patients will go on to spontaneous recovery; however, a number will require microsurgery. It is prudent for the treating clinician to recognize, document and discuss the injury with the patient prior to referring to the oral and maxillofacial surgeon trained in microsurgery.